Health Insurance Copay Meaning

Posted : admin On 1/3/2022

A copay is a fixed amount you pay for a health care service, usually when you receive the service. The amount can vary by the type of service. How it works: Your plan determines what your copay is for different types of services, and when you have one. You may have a copay before you’ve finished paying toward your deductible. What is the meaning of Co-pay in Health Insurance? Copay or Co-payment refers to a fixed amount of money you need to pay for certain types of treatment when the rest balance amount will be paid to the insurer. The can be a pre-decided amount or a percentage of the total cost of treatment depending on the policy you choose.

What is a copayment?

However, this doesn’t mean your health insurance will pay the entire bill and you won’t have to pay anything. Even though you’re done paying your deductible for the year, you may still owe coinsurance until you've met your plan's maximum out-of-pocket for the year (in most cases, coinsurance applies to services that would count towards the deductible if you hadn't already met it for the. Both copay and coinsurance help health insurance companies save money (and therefore keep your premiums lower) by making you responsible for part of your healthcare bills. Both are forms of cost sharing, meaning that you pay part of the cost of your care and the health insurance company pays part of the cost of your care. The difference between. Copay in Health Insurance refers to the percentage of the claim amount that has to be borne by the policyholder under a health insurance policy. Few insurance policies come with a mandatory clause for copayment, while others offer policyholders the option for voluntary copayment, which allows them to reduce their premium payment.

A copayment is a defined dollar amount a patient pays for medical expenses. With many health insurance plans, a patient pays 100 percent of costs out-of-pocket until they have met their deductible. After meeting the deductible, a patient pays a copayment (often shortened to “copay”).


Do I pay the same copayment for all types of healthcare services?

No. Health insurance plans set different copay amounts for different types of services, such as an emergency room visit vs. an office visit. For prescription drugs, most plans define different copayments for different categories (formulary tiers) of drugs. For example, a plan might have a $10 copay for a generic drug, $25 for a preferred brand-name drug, $50 for a non-preferred brand-name drug, and $100 for a specialty drug.

Plans may also require a mixture of copayments and coinsurance. For example, you may have a copayment for prescription drugs, but coinsurance for a hospital stay. And, insurance plans sometime “stack” copayments and coinsurance. For example, you might pay a baseline copayment of $100 for a hospital stay plus 20 percent of charges for healthcare services you receive during your stay.

Do copayments vary if I go to an in-network vs. out-of-network provider?

Yes, almost all health insurance plans require the patient to pay more for an out-of-network service. Check your certificate of insurance, certificate of coverage, or summary plan description (SPD) to understand what portion of a given medical expense you will be responsible for paying. Some plans might not cover a service provided by an out-of-network. Others may require the covered individual to pay the difference between charges from an in-network and an out-of-network provider.

If you have other forms of health care coverage (like a private insurance plan, Medicare, Medicaid, or TRICARE), you can use VA health care benefits along with these plans. Learn more about how VA works with other health insurance.

Why does VA require me to provide information on my health insurance coverage (including coverage under a spouse’s plan)?

What is copay health insurance

We ask for this information because we have to bill your private health insurance provider for any care, supplies, or medicine we provide to treat your non-service-connected conditions (illnesses or injuries that aren’t related to your military service).

We don’t bill Medicare or Medicaid, but we may bill Medicare supplemental health insurance for covered services.

What if my health insurance provider doesn’t cover all the non-service-connected care that VA bills them for?

You won’t have to pay any unpaid balance not covered by your health insurance provider. But, depending on your assigned priority group, you may have a copay for non-service-connected care.
Learn more about eligibility priority groups

Does it help me in any way to give VA my health insurance information?


Yes. Giving us your health insurance information helps you because:

  • When your private health insurance provider pays us for your non-service-connected care, we may be able to use the funds to offset part—or all—of your VA copayment.
  • Your private insurer may apply your VA health care charges toward your annual deductible (the amount of money you pay toward your care each year before your insurance starts paying for care).

Does my current health insurance status affect whether I can get VA health care benefits?

No. Whether or not you have health insurance coverage doesn’t affect the VA health care benefits you can get.

If I’m signed up for the VA health care program, does that mean I meet the requirements to have health care under the Affordable Care Act (ACA)?

What does copay mean in health insuranceCopay

Yes. Being signed up for VA health care meets your Affordable Care Act health coverage requirement of having “minimum essential health coverage.” You don’t need any other insurance to meet this requirement. We’ll update this site if the ACA changes with new laws.
Learn more about the ACA, VA, and you

Note: It’s always a good idea to let your VA doctor know if you’re receiving care outside VA. This helps your provider coordinate your care to help keep you safe and make sure you’re getting care that’s proven to work and that meets your specific needs.

More about how VA health care works with Medicare and other insurance

Health Insurance Copay Meaning Dictionary

  • This is your decision. You can save money if you drop your private health insurance, but there are risks. We encourage you to keep your insurance because:

    • We don’t normally provide care for Veterans’ family members. So, if you drop your private insurance plan, your family may not have health coverage.
    • We don’t know if Congress will provide enough funding in future years for us to care for all Veterans who are signed up for VA health care. If you’re in one of the lower priority groups, you could lose your VA health care benefits in the future. If you don’t keep your private insurance, this would leave you without health coverage.
    • If you have Medicare Part B (coverage for doctors and outpatient services) and you cancel it, you won’t be able to get it back until January of the following year. You may also have to pay a penalty to get your coverage back (called reinstating your coverage).
  • Yes. We encourage you to sign up for Medicare as soon as you can. This is because:

    • We don’t know if Congress will provide enough funding in future years for us to provide care for all Veterans who are signed up for VA health care. If you’re in one of the lower priority groups, you could lose your VA health care benefits in the future.
    • Having Medicare means you’re covered if you need to go to a non-VA hospital or doctor—so you have more options to choose from.
    • If you delay signing up for Medicare Part B (coverage for doctors and outpatient services) and then need to sign up later because you lose your VA health care benefits or need more choice in care options, you’ll pay a penalty. This penalty gets bigger each year you delay signing up—and you’ll pay it every year for the rest of your life.
    • If you sign up for Medicare Part D (coverage for prescription drugs), you’ll be able to use it to get medicine from non-VA doctors and fill your prescriptions at your local pharmacy instead of through the VA mail-order service. There’s no penalty for delaying Medicare Part D.
  • You’ll need to choose which benefits to use each time you receive care.

    To use VA benefits, you’ll need to get care at a VA medical center or other VA location. We’ll also cover your care if we pre-authorize you (meaning we give you permission ahead of time) to get services in a non-VA hospital or other care setting. Keep in mind that you may need to pay a VA copayment for non-service-connected care.

    If you go to a non-VA (or VA authorized) care facility, Medicare may pay for other services you may need during your stay. Or, if we only authorize some services in a non-VA location, then Medicare may pay for other services you may need during your stay. Check your Medicare plan, so you know which care locations and services you’re covered for.
    Learn more about Medicare

  • Yes. We may bill and accept reimbursement from High Deductible Health Plans (HDHPs) for medical care and services to treat your non-service-connected conditions. If you have an HDHP linked to an HSA, you can use your HSA to pay your VA copayments for non-service-connected care.

    We may also accept reimbursement from HRAs for care we provide to treat your non-service-connected conditions.

  • No. As a result of the VA MISSION Act of 2018, we no longer need permission to bill health insurance providers for care related to a sensitive diagnosis (like alcohol or drug abuse, alcoholism, HIV or HIV testing, sickle cell anemia, or other diagnoses included in Public Law 38 U.S.C. §7332-protected information).

    Before submitting any claims for care related to a sensitive diagnosis, we notified Veterans of this change by sending a one-time notice to all Veterans who had signed a release of information refusing to allow us to bill for care related to a sensitive diagnosis in the past. The Federal Register also published this change.

    We’re now submitting claims to health insurance carriers for all non-service-connected care, even if we don’t have a signature or written authorization permitting us to disclose protected information on these claims or in Veterans’ medical records.

    We’re required by law to bill your health insurance (including your spouse’s insurance if you’re covered under the policy). The money collected goes back to VA medical centers to support health care costs provided to all Veterans.

    You can submit a restriction request asking us not to disclose your health information for billing purposes, but we’re not required to grant your request. To submit a restriction request, please contact your nearest VA health facility and ask to talk with the privacy officer. You can also ask to talk with the billing office for more information.

More information about your benefits

Copayment Definition Health Insurance

  • Health care benefits eligibility

    Not sure if you qualify? Find out if you can get VA health care benefits.

  • How to apply for health care benefits

    Ready to apply? Get started now.

  • Health needs and conditions

    Find out how to access VA services for mental health, women’s health, and other specific needs.

  • Disability benefits

    Have an illness or injury that was caused—or made worse—by your active-duty service? Find out if you can get disability compensation (monthly payments) from VA.