Do copays count toward the deductible?
It depends on the plan. On some plans copays count toward the deductible and on others they do not. Copays generally do count toward the out-of-pocket maximum for covered in-network care, but confirm in your plan documents.
What is behind the short answer.
The short answer is above. These are the details that decide it for a specific plan.
Plans differ
Some plans apply copays to the deductible. Others treat copay services as separate from it. The plan summary and plan documents are what decide.
Where to look
The summary of benefits and coverage notes whether a service is subject to the deductible. A service marked as not subject to it is typically covered with a copay.
Why it matters
If copays do not count toward the deductible, an employee can pay many copays and still have the full deductible ahead of them for a larger claim.
Ask once
The carrier or your benefits team can confirm how your specific plan counts copays in a minute. It is a good question to ask before enrollment.
Six copay visits and a hospital bill.
A member pays six $30 copays and then a $1,200 hospital charge that goes to the deductible. Whether the copays count toward a $1,500 deductible depends on the plan.
Illustrative figures. Check the plan summary for whether copays apply to the deductible. Copays for covered in-network care generally do count toward the out-of-pocket maximum.
We check how each plan counts copays before you compare.
Counting rules are the kind of detail that differs by carrier and plan. We read them on every option so the comparison is accurate.
Related pages.
The Copay, Explained in Plain Terms
A copay is a fixed dollar amount an employee pays for a specific service, such as a primary care visit or a prescription.
The Deductible, Explained in Plain Terms
A deductible is the amount an employee pays for covered care before the plan starts sharing the cost.
Health Plan Terms That Sound Alike
Copay and coinsurance, deductible and out-of-pocket maximum, premium and cost of care.
Avoiding Group Health Insurance Plan Confusion
The full guide to helping employees understand their group health plan.
Questions that come up next.
Short answers to the questions employees ask after this one. Each links to its own page.
Is coinsurance the same as a copay?
No. A copay is a fixed dollar amount for a specific service. Coinsurance is a percentage of the cost of a covered service that the employee pays after the deductible is met.
What counts toward the out-of-pocket maximum?
Generally the deductible, copays and coinsurance for covered, in-network care count. Premiums, services the plan does not cover and, in most plans, out-of-network care do not.
Why did we get a bill after a visit that only had a copay?
Because the copay usually covers the visit itself and not everything billed around it. Lab work, imaging, a procedure, a facility fee or an out-of-network provider can each be billed separately.
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General information about group health plan terms, not legal or tax advice. Plan-specific questions belong with the plan documents and the carrier.
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