What is a copayment?

In today's complex healthcare landscape, having a good understanding of health coverage and medical terminology is essential. One term that often comes up when shopping for a plan or reviewing a medical bill is copayment, which is a set amount you’ll pay for a covered healthcare service, such as a physician visit or a prescription.

If you're enrolling in a plan for the first time, switching policies during Open Enrollment, or using a health reimbursement arrangement (HRA) to help pay for coverage, it's important to look at more than just the monthly premium. Copayments and other cost-sharing amounts vary significantly between plans and can affect the total amount you’ll pay for receiving medical care.

In this blog post, you’ll learn:

• What a copayment is and how copays work with deductibles, coinsurance, and out-of-pocket maximums.
• How to compare copay amounts when choosing a health insurance plan during Open Enrollment.
• How health savings accounts (HSAs), flexible spending accounts (FSAs), and HRAs can help you pay for eligible copay expenses.

Definition of a copayment

A copayment, also known as a copay, is a fixed amount of money (such as $20) that you pay for a covered medical service or item. Copayments are a form of cost-sharing between you and your insurance provider. The insurance company pays its share of the covered expense in accordance with your plan's terms, and you pay the copay.

Both individual and traditional group health plans can have copays. However, the exact amount you’ll pay depends on your plan type, your insurance company, and the healthcare service you receive.

Copayments are often confused with coinsurance and deductibles, but they're different. A copay is a specific dollar amount the policyholder pays for a particular visit or service, while coinsurance is a percentage of the cost of a covered service. A deductible is the amount you’ll pay for certain covered services before your plan begins paying your medical expenses.

Keep in mind that some plans charge copays for certain services before you meet your deductible, while other services require you to meet your deductible first. Your policy’s documents will outline when a copay applies so you can plan accordingly.

When do I have to pay a copay?

Common medical services that may require a copay include the following:

• Doctor's office visits, such as a primary care visit for non-preventive care services
• Specialist care visits
• Urgent care visits
• Prescription drugs
• Physical therapy
• Mental health counseling
• Hospital visits

Copays aren't limited to office visits. The amount and type of cost-sharing for hospital care, outpatient services, lab work, prescription drugs, and other services depend on the plan.

According to KFF's 2025 Employee Health Benefits Survey, 11% of respondents with an employer-sponsored group health plan had a copayment for inpatient hospital admission¹. The survey also found that 13% had a copay for outpatient surgery. Individual Marketplace plans can have different copayment structures and amounts.

Medical providers typically require you to pay your copay at the time of service. For instance, when you check in at a doctor's office, you may be asked to pay the copay before seeing the doctor. Alternatively, some doctors' offices may bill you for the copay after the visit.

Thanks to the Affordable Care Act (ACA), preventive care services are exempt from cost-sharing when provided by an in-network provider. If you go outside your plan's network, you may have to pay full price or the standard cost-sharing amount.

The following preventive care expenses are usually exempt from copays²:

• Wellness exams and annual checkups
• Blood pressure screening
• Vaccinations
• HIV screening
• Depression screening

How do copayments work?

Most types of health plans charge a fixed copay for certain services before you meet your annual deductible, while other services may be subject to the deductible or coinsurance first. For example, a plan might charge a $30 copay for an in-network primary care visit before you meet your deductible. The same plan could require you to pay the full allowed cost of a lab test until you've reached your deductible.

However, copayments vary by plan. Your plan documents or Summary of Benefits and Coverage (SBC) will explain which covered services require a copay.

When do I have to pay my copay?

When a copayment is due depends on your plan's terms. Some providers require payment at the time of service, while others bill you later.

There are also exceptions to payment timing, such as emergency care or hospital admissions. Under federal law, hospitals generally can't deny you emergency services and stabilizing treatment based on your ability to pay upfront.³

Do copays count toward my deductible?

It depends on the health plan. Some copayments count toward the deductible, while others don't. When you review your policy details, you should be able to see if your insurer will apply any copayments you make for doctor visits, prescription medications, or other services toward your deductible.

Do I still pay a copay after I reach my out-of-pocket maximum?

Generally, no. Once you've reached your plan's out-of-pocket maximum for covered, in-network services, your insurance carrier will typically pay for the entire cost of covered benefits for the rest of the plan year.

In most cases, copayments, deductibles, and coinsurance will count toward your in-network out-of-pocket max. However, premiums, out-of-network costs, and medical services the plan doesn't typically cover won’t count.

Example of a copayment

Let's see a copayment in action. Let's say a health insurance plan requires a $20 copayment for a primary care physician visit, a $50 copayment for a specialist visit, and a $10 copayment for generic prescription drugs.

This plan applies these fixed copayments to the applicable services. The plan also specifies that these copayments count toward the individual's $5,000 out-of-pocket maximum.

Suppose the individual has already paid $4,000 toward the out-of-pocket maximum for the year. When they have a primary care visit covered by the $20 copay, they pay $20. Assuming it’s a covered service and the $20 copay qualifies as an in-network out-of-pocket expense under the plan, the amount brings their total to $4,020.

How can I use copays to compare health plans during Open Enrollment?

If you're shopping for a health plan during Open Enrollment, it’s vital to look at all the costs involved. You can find each plan’s deductible, copays, and coinsurance amounts in the SBC, which is typically available from the exchanges. Compare the copays for the services you expect to use most often, along with the plan's premium, deductible, coinsurance, and out-of-pocket maximum amount.

The comparison chart below is an example of two health plans’ potential costs:

Plan A has the lower monthly premium, but Plan B has lower copays, a lower deductible, and a lower out-of-pocket maximum. If you expect you’ll need a lot of medical care during the plan year, Plan B could mean you’ll pay less overall despite its higher premium.

What are some factors that affect copayments?

Many factors can affect whether or not you have to pay copayments and what the amount might be:

1. Health insurance coverage: Different insurance plans have different copayment structures. Some plans may have fixed copayments for all services, while others may have tiered copayments for different types of services.
2. Provider network: Some insurance plans require higher copayments for covered services provided by out-of-network providers, while in-network providers may have lower copayments.
3. Type of medical service: The copayment amount can vary based on the type of service you receive. For example, a specialist visit may have a higher copayment than a primary care doctor visit.
4. Prescription drugs: Copayments can vary by drug type. For example, copayments are often lower for generic prescriptions than for name-brand products.

We'll review some of these differences in more detail.

Health insurance coverage

Cost sharing can help keep premiums lower by requiring members to pay part of the cost when they use healthcare services. The tradeoff is that plans with lower premiums may have higher out-of-pocket costs when you receive care.

Health plans — including health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS) plans — may use copayments, coinsurance, deductibles, or a combination of these to structure their cost-sharing.

However, the plan type isn’t the sole factor in whether you'll have a copay or how much it will be. Two PPOs, for example, can have different covered services and different copayments. So check your plan details carefully when comparing options.

In-network vs. out-of-network care

Whether you receive in-network and out-of-network care can affect your cost-sharing. In-network health providers typically have negotiated rates with your insurance carrier, which means you'll typically pay less for covered care.

Out-of-network providers may have higher cost-sharing, or your plan may not cover their services at all. Some policies also use separate deductibles or out-of-pocket maximums for out-of-network care.

When comparing plans, check whether your preferred doctors, hospitals, and other providers are in-network. You should also review whether your insurance policy covers your prescriptions and what drug tier they fall into.

What is the average cost of a copayment?

The cost of a copayment varies depending on the type of service and health insurance coverage. So, it’s important to check the actual copay listed in the plan's SBC before enrolling in the policy. However, to give you an idea, the typical average copayment for a regular doctor’s visit is around $20 to $40. In contrast, a specialty care visit may have a higher copayment of $50 to $100.

According to the KFF survey, 66% of employees with group health insurance plans in 2025 paid a copayment for an in-network primary care visit, while 65% paid a copayment for an in-network specialist visit. Among plans with copayments, the average copay was $27 for primary care and $45 for specialty care.

Can I use an HSA or FSA for copayments?

Yes, you can use either a health savings account (HSA) or a health flexible spending account (FSA) to cover your copay expenses. But you'll need a qualifying high deductible health plan (HDHP) to contribute to an HSA.

For 2027, a qualifying HDHP must have a minimum annual deductible of $1,750 for self-only plans or $3,500 for family coverage. Annual out-of-pocket costs must not exceed $8,700 for self-only coverage or $17,400 for family policies⁴.

Additionally, on-exchange bronze policies and catastrophic health plans are HSA-compatible as of 2026, regardless of whether they meet the general HDHP definition. Their mirrored off-exchange versions are also HSA-qualified.

Can my HRA reimburse my copayments?

Yes, an HRA allows employers to reimburse employees tax-free for qualifying medical expenses listed in IRC § 213(d), including copays⁵. However, it depends on how your employer designed your benefit.

For example, an employer could design an HRA to reimburse eligible out-of-pocket healthcare expenses and health insurance premiums. Or they could limit reimbursements to premiums only.

Because an HRA offers flexible design options, verify with your company’s benefits specialist or HRA administrator if your HRA allows reimbursement for premiums as well as out-of-pocket expenses like copayments.

How can an HRA factor into my health plan choice?

If you're choosing an individual health plan so you can participate and take advantage of an HRA, consider your benefit’s allowance as well as your health plan's cost-sharing amount.

For example, a plan with a $500 monthly premium and lower copays may appear more expensive than one with a $400 premium and higher copays. But if your employer provides you with an HRA allowance that reimburses most or all of your premium, the amount you pay out-of-pocket may be significantly lower.

Similarly, if your HRA reimburses other eligible expenses besides premiums, you may be able to take on more cost-sharing as you’ll receive the cost back as a tax-free reimbursement.

Ultimately, you should consider the full cost of coverage, your HRA allowance, expected healthcare use, cost-sharing, and the out-of-pocket maximum to determine the best plan for you and your family.

Conclusion

Copays are only one part of your health insurance costs. But they can make a big difference in what you’ll spend throughout the plan year. During Open Enrollment, it’s a good decision to compare a plan’s copays alongside monthly premiums and other potential out-of-pocket expenses. Looking at the entire cost-sharing structure, as well as your employer-provided allowance if you have an HRA, can give you a better picture of what each plan may cost based on your expected medical needs.

This article was originally published on January 16, 2024. It was last updated on August 25, 2026.

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