When Is a Copay Not Required?

If health insurance policies simply read, "You pay this amount each time," maybe they wouldn't be so confusing. Unfortunately, each policy refers to copayments, coinsurance and a slew of other words that most people don't use in everyday conversations. While you'll always have a copayment requirement for a health insurance plan, you may not have to pay one each time you visit the doctor or pick up your prescription medicine.

What Is a Copay?

• Copays are unique to medical insurance policies. A copay is a payment rendered to a health practitioner, hospital or pharmacy for an appointment, treatment, diagnosis or prescription. All health insurance policies require some sort of copay. A copay is often confused with coinsurance, but is completely different. Coinsurance is the percentage of medical costs you're responsible for. A copay is a set amount of money you must pay each time you visit a doctor or hospital.

Provider and Plan

• The type of health care policy you choose dictates your copay requirements. Some plans do not require a copay for doctor visits, but may require a $20 copay for prescription drugs. Other plans may require a $15 copay for doctor visits and a $20 copay for prescription drugs. Fewer copays or less expensive copays do not indicate the worthiness of a health insurance policy. While a health insurance plan with $0 copays for doctor visits may greatly benefit you if you frequently visit the doctor, the same plan may require a 30 percent coinsurance; whereas, another plan requires a $15 copay but only 10 percent coinsurance.

Waiving a Copay

• Doctors in certain states have the option of waiving a patient's copay, although that decision is dictated by the state's laws. Even in states that do allow for doctors to waive a patient's copay, a doctor is by no means required to do so. Generally, if you're in financial trouble, a doctor will waive your copay at least once, if possible, but it's unlikely to happen each time you schedule an appointment.

Tiers

• When you apply for health insurance, the health insurance company reviews your application and any prior or current conditions you may have. The company then assigns you to a tier, generally one through four. Tier one consist of the best benefits, while tier four is the most costly. Aside from a higher premium, your tier affects your copay amount. For example, if you are assigned to tier one, you may pay only a $15 copay for prescription drugs. If you're assigned to tier three, you may pay a $25 copay.