I had an appointment today with an ENT. My insurance says I have a $60 copay for specialist dr visits, so that’s what I brought to the appointment. The receptionist told me “so you have a $750 deductible on your contract, how much can you pay today?” My insurance card does mention a $750 deductible. I asked “well how much do I need to pay” and she said something like $30. So I asked if that was in addition to my $60 copay. Then she said, no that’s a percentage of the deductible (no idea what she means by that.” But then she said “if your insurance says copay is $60 then pay $60” and she said an office visit is actually $200 and insurance won’t pay until I’ve met my deductible, but that the doctor and I will get a discount through my insurance and my $60 copay will count towards the $200. Basically I’m very confused about deductible vs copay and how they relate to each other.
In: Economics
A deductible is some amount that must be paid by the patient before *any* amount gets paid out by insurance. There might be more than one deductible, such as one for medication and one for procedures, and there might be an individual deductible and a family deductible.
A copay is some amount that must be paid out even after the deductible has been met. This might be a different amount for different things.
For example, imagine I need some medication that costs $100 a week. I have an average $1700 deductible. The first 17 weeks I’m paying 100%. After 17 weeks, I’ve paid my deductible, so insurance will start covering. The copay might be $12 for medication, so every time I get more meds, I’m paying $12 for the copay, and then the insurance covers the rest.
I’ve got a $3000 deductible and a $7000 out of pocket through my work. I broke my ankle and had to have immediate surgery on the 15th of January and somehow, despite me not paying any of that yet, I have met both my deductible and out of pocket. Not sure how any of this works, but it’s made insulin and everything else much much cheaper. I feel like this shit is set up to be intentionally difficult to understand
Welcome to the hell that is US healthcare. You’re screwed. Even if someone explains this to you very well now, you will forget it by next time it happens to you. By then your insurance plan will change anyway because you changed jobs. You will spend the rest of your life in this hell, because US politicians are too paid off to implement universal health care.
I’m oversimplifying but this is ELI5…
Copay is how much you have to pay each time you have an appointment. Your insurance doesn’t cover copay.
Deductible is the maximum amount you have to pay each year for medical stuff. Once you’ve spent more than the deductible, your insurance pays instead.
Example: Your copay is $50. Your deductible is $500. In one year you have two doctor appointments and tests that cost $800. That means that in addition to whatever you are paying for insurance, in that year you will pay $100 in copays and $300 for tests.
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