Do Copays Have to Be Paid Upfront? Everything You Need to Know

Copays can be confusing, especially if you’re new to dealing with health insurance and medical bills. You may be wondering – do I really have to pay this copay, and do I have to pay it upfront before my appointment?

The short answer is: it depends. There are a few different factors that determine whether or not a copay must be paid upfront. Keep reading to learn everything you need to know about copays and when they are due.

What is a Copay?

First, let’s start with the basics. A copay is a fixed amount that you pay for a covered health care service. Copays are paid per visit, procedure, prescription drug order, equipment use, etc.

For example, you may have a $25 copay every time you visit your primary care doctor or a $10 copay whenever you fill a prescription.

Copays are in addition to your monthly health insurance premiums. They help cover a portion of the costs of your care that your insurance doesn’t cover.

Copays can vary based on your specific health insurance plan. Plans that have higher monthly premiums often have lower copays, and vice versa.

Do Copays Have to Be Paid Upfront?

Whether or not a copay has to be paid upfront depends on a few factors:

• The provider’s policies – Some provider offices and pharmacies require that copays are paid when services are rendered. Others will send a bill later for copays owed.

• The insurance plan rules – Some health plans require that copays are collected upfront from the patient, while others leave it up to the provider to determine when to collect copays.

• Deductible status – If you have a deductible that has not yet been met, you may have to pay the full cost of the service upfront rather than just the copay amount.

• Service type – A doctor’s visit copay is typically due upfront, while a hospital copay may be billed after services are provided.

However, it’s wise to be prepared to pay copays at the time of your appointment when possible.

Upfront Copay Collection Practices

Here is some more detail on when providers and insurance plans typically require upfront copay collection:

Doctor’s Office Visits

• Primary care and specialist visits – Copays are typically due at the time of the visit. The provider wants to collect the copay upfront before you are seen by the doctor.

• Urgent care clinics – Most urgent care centers will collect the copay when you check in for your appointment.

• Physical therapy – Physical therapy offices usually require copays at the time of each session.

Hospital Services

• Emergency room – ERs do not require payment upfront but you will likely receive a bill for the copay later.

• Inpatient stay – Hospital copays are usually not required upfront for scheduled procedures. You’ll get a bill later for your copay amount.

• Outpatient services – Outpatient hospital copays may or may not be collected upfront, depending on the hospital policy.

Prescription Drugs

• Retail pharmacy – Pharmacies almost always collect prescription copays when you pick up medications.

• Mail order pharmacy – Copays have to be paid upfront before a mail order pharmacy will ship drugs.

Health Insurance Plan Rules

Some specific health plans have rules requiring that copays are paid before services are rendered:

• Medicare Advantage plans may require upfront copay collection.

• Medicaid plans typically do not allow providers to deny care due to inability to pay copays upfront.

• Marketplace insurance plans on Healthcare.gov have flexibility to determine copay collection policies.

Always check your plan documents or call member services to find out your insurance plan’s copay policies.

Provider Copay Collection Policies

As mentioned above, copay collection often comes down to the provider’s office policy. Here are some things that impact a provider’s decision to collect copays upfront:

• Providers want to ensure they get paid something, even if the insurance claim is denied later on. Collecting the copay upfront guarantees at least some payment.

• It can be administratively difficult for providers to track down patients later to collect owed copays. Requiring payment upfront is easier.

• Many provider office computer systems are set up to collect copays automatically at check in. Turning off upfront collection creates extra work.

• However, providers also do not want to turn patients away who cannot afford copays. They will work out payment plans when needed.

When you make appointments, always ask if the copay is due upfront so you know to bring your payment method. If paying your copay upfront will be difficult, discuss options with the provider ahead of time.

Paying Copays When You Have a Deductible

If you have a deductible on your health plan, you may have to pay the full negotiated rate for a service upfront rather than just a copay. This occurs when:

• Your deductible applies to the service category (e.g. doctor visit, hospital care, prescription drugs).

• You have not yet paid out enough expenses to meet your deductible for the year.

• The cost of the service is less than your remaining deductible amount.

In this scenario, no copay is charged because your deductible has to be satisfied first. You pay the full negotiated rate until your deductible is met.

For example, if you have a $2,000 deductible and $1,500 has been applied to it so far this year, you have $500 left to pay. If you have an office visit that costs $200 total, you’ll pay the $200 rather than your typical $25 copay.

Always check if you’ve met your deductible before copays apply when you receive medical services. Your explanation of benefits will outline if your deductible or copay was charged.

What If You Can’t Afford the Upfront Copay?

It’s quite common for people to struggle to pay their copays, especially hospital and emergency copays that can be hundreds of dollars. Here are some things you can do if you cannot afford an upfront copay:

• Ask for a discount – Uninsured and underinsured patients can ask for copay assistance or fee reductions. Many facilities have financial assistance programs.

• Request a payment plan – Most hospitals and large medical practices will work out installment plans for large copays or high deductibles. Set up automated payments over 3-6 months.

• Use a credit card – Charging the copay to a credit card allows you to pay it over time. Try to find a card with a 0% intro APR period.

• Borrow from a HSA/FSA – If you have money in a health savings account or flex spending account, use it to cover copays you can’t afford out-of-pocket.

• Apply for charity care – Hospital financial assistance programs provide care free or at discount for low-income uninsured patients.

Never avoid necessary medical treatment because you cannot afford copays. Always explain your financial situation and ask about assistance options.

Tips for Managing Medical Copays

Managing copays and health expenses can be challenging. Here are some tips to stay on top of payments owed:

• Keep a record of copays you pay at each appointment and add them up throughout the year.

• Save explanation of benefits statements to track copays charged and your deductible status.

• Understand your insurer’s copay policies – do they have copay waivers or accumulators?

• Know your out-of-pocket maximum amount so you can anticipate when copays will end for the year.

• Put recurring copay amounts in your budget (e.g. monthly prescriptions).

• Ask your provider for invoices or statements for copays you owe for easier tracking.

• Automate and consolidate medical bills when possible through online bill pay.

Staying organized with copays helps ensure you don’t miss payments and accrue unnecessary interest or penalties.

Do You Have to Pay Copays for Preventive Care?

One copay exception you’ll want to be aware of is preventive care. Under the Affordable Care Act (ACA), health insurance plans must cover a set of preventive services at no cost to patients.

This means you do not have to pay copays, deductibles, or other out-of-pocket costs for:

• Routine health screenings and checkups

• Immunizations and vaccinations

• Certain women’s health services like pap smears

• Well child visits and pediatric services

• Chronic disease management programs

• Smoking cessation treatment

• And more, as specified by the ACA

As long as you meet the guidelines and get care from an in-network provider, your preventive visits and screenings will be 100% covered with no