To put it plainly, a copay is the amount you and your insurance agree you will pay for care. Your copay is a fixed dollar amount for an entire benefit year and contributes to your “out-of-pocket-maximum.”
Copay is not a discount or a coupon because the amount you pay is always static to the health care event. Copay is essentially a special rate that your insurance has negotiated for you.
Copay varies from plan to plan, carrier to carrier, but it does not vary within a network. If you have a $20 copay for a checkup, you will pay $20 for that checkup so long as you’re seeing your assigned primary care physician.
Since copay is based on the type of care you’re looking for, that special rate does have some restrictions. For example, you only receive your copay rate with what ends up on your itemized doctor bill. Meaning, if you go to the doctors for a checkup and they give you an X-Ray, you will have to pay whatever rate is reflected on your EOB (Explanation of Benefits).
In this case, you’d pay the copay for your physical as well as your X-Ray.
What’s the difference between Coinsurance and Copay?
Coinsurance is a percentage-based rate. You pay a portion of your hospital bill based on the cost of the procedure. A 15% coinsurance means you’ll pay 15% of whatever the costs of the procedure are. Meaning, if you get surgery that costs $10,000, you will only pay $1,500 and your insurance will cover the rest.
Both coinsurance and copay are factored into your “out-of-pocket-maximum" which is the most you’ll ever have to spend on health care covered by Sharp in a given benefit year.
You can only enroll in Sharp Healthcare during open enrollment, in the first 30 days of being hired/promoted, or within 30 days of a QLE (Qualifying Life Event: basically, big moments in your life, like: when something changes your insurance status, you have a child, or retire).
Remember copay only kicks in AFTER your deductible is paid if you have the Sharp Saver plan. Meaning, you’re responsible for the first $1,000 in medical expenses.
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