According to recent statistics, over 50% of American workers have an annual deductible of $1,000 or more. And, a typical co-pay for an in-network provider can be anywhere from $25 to up to $100 per visit for urgent care services. We’re throwing quite a few numbers at you, but what do they really mean?
When it comes to co-pay vs. deductible, you’re talking about health care costs. And while co-pays and deductibles are related, they’re also independent of each other. Confusing? We’ll break it down nice and easy for you.
What’s a co-pay?
When signing up for a health care plan, you’ll most likely be presented with an overview of the costs, including the plan’s premium (monthly cost), the deductible, and the co-pay. There’s more to health care than just these initial figures (oh boy, is there more), but these are some of the most important to look at upfront.
A co-pay is a fee you’re charged each time you visit a provider. Usually, you’ll pay different fees depending on the provider, whether they’re your general practitioner, a specialist, or an urgent care provider. You’ll encounter co-pays when it comes to other services, such as prescription drug costs, physical therapy, and certain lab tests.
Important Note: Don’t get co-pay confused with coinsurance.
What’s a deductible?
In simple terms, a health care deductible is the value of money you have to pay before your health insurance begins covering costs for you. We know what you’re thinking. “I’m paying for a monthly insurance plan and now I have to pay more on top of that?” Yeah, it sucks, we know. Unfortunately, that’s how insurance works.
If your deductible is $2,000, you have to pay $2,000 in health care costs for visits and services out of your own pocket. After you spend $2,000 (if you ever need to, that is), then your insurance will kick in, and they’ll start covering those costs. This is when your co-pay comes into play.
Depending on your plan (more on that below), you’ll likely have a co-pay for visits and prescriptions after meeting your deductible. So, let’s say that you meet your deductible of $2,000, what are you expected to pay? You’ll always have to pay your monthly premium (think of it like your Netflix subscription; it’s recurring) and, depending on your plan, co-pays for things like visits and prescriptions.
Co-pay vs. deductible: are they related?
Remember when we said it’s important to look at these numbers upfront when comparing health care plans? Well, why is it important? The terms vary from plan to plan. Some plans treat co-pays and deductibles as separate issues while other plans allow you to use co-pay fees and put them towards meeting your deductible.
If you’re responsible for co-pays, this will be laid out clearly before you opt-in to the plan. Typically, it will be clear whether or not those co-pays help you work towards meeting your deductible. Regardless, be sure to check the out-of-pocket maximum that you’re expected to pay.
For this plan below, which is part of Covered California, the out-of-pocket maximum is $8,200, so regardless of what your deductible or co-pays are, you’ll never have to pay more than $8,200 in medical costs out of your own pocket for that year of coverage. Take a look at the listed co-pays, though. They vary by state and by plan, but the basic rule of thumb is the same: they list them clearly (somewhat) while you’re comparing plans.
What about the relationship between co-pay and deductible when it comes to the pricing of individual plans? While it’s true that plans with higher monthly premiums typically come with lower deductibles, the same isn’t always true for the cost of co-pays. They really vary from plan-to-plan, so that’s why it’s best to browse around quite a bit before making your decision.
FAQs: co-pay vs. deductible costs
You’ve got questions about the costs of co-pays and deductibles, and you’re not alone. Here are some of the most common questions about this aspect of health coverage.
Are deductibles yearly or monthly? Yearly, thankfully! So, if your deductible is $2,000 and you meet that in the first two months of your coverage, for example, you’re good for the rest of the year.
Do you pay a deductible if you never use your health insurance? Nope. It’s only for medical services and prescription costs that you use. For example, if you never visit the doctor this year and don’t need any other health-related services, you don’t pay anything aside from your monthly premium.
Is my co-pay always the same? For each individual service, yes. In the example above with Covered California, you’ll see that a doctor’s visit costs $35. That will be the same every time you visit until you meet your out-of-pocket maximum.
So I have to pay for literally everything out-of-pocket before meeting my deductible? Not everything, no. Often, preventative care services are free under most health plans. But, in terms of doctor’s visits, surgeries, and other significant costs, yeah, you have to pay those out-of-pocket.
Is it possible to have a $0 co-pay? Yes! It’s not that uncommon, actually. However, this usually only applies to things like primary care visits and generic prescriptions, not larger costs such as surgeries and lab tests.
Getting help with health insurance
Health insurance is confusing, and we’ve been where you are. It’s why we created onomy in the first place. If you’re still having trouble getting the hang of deductibles, and co-pays, check out our super easy-to-understand guide here. We’ll give you simple tips on everything you need to know in order to navigate health care yourself (think of it as a way to show off your life skills at the virtual dinner table this holiday season).