Understanding Copay Plans

Friday Health Plans is offering copay plans in 2022. You might be wondering what this means and if one of these plans is suitable for you.

A “copay” is a fixed dollar amount you pay for a specific covered health expense. It doesn’t count towards your deductible, and you must continue to pay them after you’ve met your deductible. You usually pay it when you receive the service (such as a $25 copay for an office visit.) These costs don’t count towards your deductible.

A “deductible” is the amount you pay for covered health services before your insurance plan begins to pay.

Copay plans are offered in Bronze, Silver, and Gold categories and provided as Copay, Copay Plus, and Rx Copay (for Colorado only) plans.

Pros of Copay Plans:

  • Copay Plans are great for people who visit doctors more often, such as families with kids.
  • You will always know the amount you owe because it is a set dollar amount.
  • It still counts towards your Maximum out of Pocket (the most you’ll need to pay during the year for covered health care services).
  • You will need to meet your deductible for some services first (pay the total amount), but after that, you will only owe the copay amount.
  • Specific plans, like Plus and Rx copay plans, help you have a lower cost for drugs or special services. You pay a higher premium for this.
  • These plans have a lower deductible.

Cons of Copay Plans:

  • You will pay a higher monthly premium.
  • If you don’t go to the doctor often, it may not be the best fit for you.

Examples:

You and your family (your spouse is on the plan, and you have two kids) are shopping for insurance. You know you want a silver plan, but you don’t know if you want a Silver or Silver Copay plan. Here* is the difference:

  • Premium Cost: $1,297.35/month ($15,568.20/year) Silver Plan vs. $1,368.54/month ($16,422.48) Silver Copay Plan
  • Deductible: $11,000 Silver Plan vs. $8,600 Silver Copay Plan
  • Maximum out of Pocket: $17,100 for both plans
  • Generic Drugs: $0 for both plans
  • Specialty Drugs: 50% coinsurance after deductible (means you pay total price till you meet your deductible, then you pay 50% of the cost) Silver Plan vs. $425 copay Silver Copay Plan
  • Specialist Visit: 20% coinsurance after deductible (means you pay total price till you meet your deductible, then you pay 20% of the cost) Silver Plan vs. $80 copay Silver Copay Plan
  • Urgent Care Visit: 20% coinsurance after deductible Silver Plan vs. $100 Copay Plan
  • Emergency Visit: 50% coinsurance after deductible Silver Plan vs. 30% after deductible Silver Copay Plan
  • Primary Care Visit: $0 for both plans
  • Telehealth visit: $0 for both plans

Now, let’s say you have a normal and healthy year:

  • Premiums: $15,568.20/year Silver Plan vs. $16,422.48 Silver Copay Plan
    • $854.28 difference in cost
  • Everyone goes to the primary care doctor: $0 for both plans
  • One of the adults goes to therapy to grieve a loss in the family: $0 for both plans
  • You get allergy meds for one of the kids, and one of the parents takes a prescription, both generic: $0 both plans
  • The kids get sick, and you go to urgent care: $300 Silver Plan vs. $200 Silver Copay Plan
  • One of the adults visits a specialist twice: $500 Silver Plan vs. $150 Silver Copay Plan

Totals:
Silver Plan: $16,368.20
Silver Copay Play: $16,772.48
Difference: Silver Copay would cost more on a year where you rely on your insurance less. ($404.28 more).

If you use your health plan frequently, because your kids are accident-prone and you’re trying to figure out one of the adult’s knee problems with a specialist:

  • Premiums: $15,568.20/year Silver Plan vs. $16,422.48 Silver Copay Plan
    • $854.28 difference in cost
  • Everyone goes to the primary care doctor: $0 for both plans.
  • One of the adults goes to therapy for stress: $0 for both plans.
  • You get allergy meds for one of the kids, and one of the parents takes a prescription, both generic: $0 for both plans.
  • One kid breaks an ankle at a soccer game, the other sprains a wrist skiing, the whole family gets the flu, and you go to urgent care three times: $900 Silver Plan vs. $600 Silver Copay Plan.
  • The adult trying to figure out a solution for their knee goes to the specialist five times and gets surgery: $2,000 Silver Plan vs. $875 Silver Copay Plan.

Totals:
Silver Plan: $18,468.20
Silver Copay Plan: $17,897.48
Difference: Silver Copay would cost less on a year where you rely on your insurance more heavily. ($570.72 more).

In the event of a catastrophe, such as a bad car accident that lands you or your whole family in the Emergency Room, and the cost was more than your Maximum out of Pocket ($17,100), you wouldn’t pay more for anything, including copays the rest of the year. A Silver Copay Plan would still cost more, however, because of the higher premium costs.

So, is a Copay Plan right for you? If you use your plan a lot, the answer is yes. Have questions? Contact the Friday Care Crew or email questions@fridayhealthplans.com.

*These are estimated prices that will vary based on your information.

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