Copay
A fixed dollar amount you pay for a covered health care service at the time of service, regardless of the total cost.
A copay (short for copayment) is a predetermined flat fee that a health insurance member pays for a specific covered service—for example, $25 for a primary care visit, $50 for a specialist, or $10 for a generic prescription. The copay is paid at the time of service; the insurer covers the remaining cost.
Copays are a form of cost-sharing designed to discourage excessive utilization while keeping health care accessible. They differ from coinsurance, which is a percentage of the cost rather than a flat fee. Copay amounts vary by plan type: HMO and EPO plans often have copays for most services; high-deductible health plans (HDHPs) typically have no copays until the deductible is met (preventive care excepted).
Some services are exempt from copays under the ACA: preventive services rated A or B by the USPSTF (annual physicals, vaccinations, certain screenings) must be covered without cost-sharing. This means no copay, no deductible, and no coinsurance applies to these services on compliant plans.
Real-World Example
The insured paid a $35 copay for her urgent care visit; the insurer covered the remaining $185 billed by the clinic.