Whenhealth insurance deductiblesare often measured in thousands of dollars, copayments—the fixed amount (usually in the range of $25 to $75) you owe each time you go to the doctor or fill a prescription—may seem like chump change.
But copays really add up when you have ongoing health conditions. And for more expensive services, like urgent care and emergency room visits, copays can be $100 or more. And you may be wondering: Do copays count toward your health insurance deductible? Are you chipping away at your massive deductible each time you pay the $30 copay for your thyroid or cholesterol prescription?
This article will explain what you need to know about how this typically works, but you should carefully read your own policy details to be sure you know exactly how your specific coverage is structured.
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Does Your Copay Count Toward Your Deductible?
It’s natural to cringe when you think about your health insurance deductible, often a few thousand dollars.Budgeting for your health insurance deductiblehas become a must for financially savvy folks who aren’t wealthy. But, it’s hard to track your progress towards meeting your deductible if you don’t understand what, exactly,counts toward it.
Whether or not your copays count toward your deductible depends on how your health plan has structured itscost-sharingrequirements.Most plans do not count your copays toward your health insurance deductible.However, your plan might. Health plan cost-sharing requirements change each year as health plans look for new, cost-effective and consumer-friendly ways to structure cost-sharing requirements.
How do you know for sure? First, check yourSummary of Benefits and Coverage. Pay close attention to the math in the examples. If it’s still not clear, you may need to call the member number on your health insurance card and ask.
But in general, you should expect that your copays will not be counted towards your deductible. They will, however, be counted towards yourmaximum out-of-pocket(unless you have a grandmothered or grandfathered plan that uses different rules for out-of-pocket costs).
Anytime you get a new health plan, it’s a good idea to carefully review the details of how the plan’s cost-sharing works. That will give you a good idea of what to expect if and when you need medical care, whether it’s minor (often covered with a copay) or major (much more likely to be subject to the deductible and coinsurance).
Copays Can Add Up Fast
Even though your plan likely does not count copays toward your deductible, it will almost certainly count them toward your maximum out-of-pocket limit. Once you reach that cap (which can be a combination of copays, deductible, andcoinsurance), your health plan should pay for any covered care you need for the rest of the year, assuming that you use in-network providers and comply with any rules your plan has, such asprior authorizationor step therapy.
Most health plans apply the cost of some services towards the deductible and use copayments for separate services, which means that your copays and deductible obligations generally won’t apply to the same service.
But keep in mind that two different “services” can be performed simultaneously, such as an office visit that includes lab work. In that case, the office visit might have a copay and the lab work might have a separate charge that counts toward your deductible.
Let’s say your health insurance is structured like this:
In January, you’re diagnosed withdiabetes. You see your PCP three times and are prescribed one generic drug and one brand-name drug. Your January copayments are $30 + $30 + $30 + $25 + $45 = $160.
Your PCP isn’t happy with your diabetes control, so in February, she sends you to see anendocrinologist, a physician who specializes in diabetes and hormone problems. You see the specialist and refill both of your prescriptions. Your February copayments are $60 + $25 + $45 = $130.
In March, you see the endocrinologist twice. She changes your prescriptions; you’re now on two brand-name drugs. Your March copayments are $60 + $60 + $45 + $45 = $210. In March your endocrinologist also orders another test and it costs you $130 (again, this is counted towards your deductible, and you have to pay for it in addition to the copay you’re charged for seeing the doctor).
By the end of March, you’ve paid a total of $500 in copayments for office visits and prescriptions, plus $370 towards your deductible. You still have to spend $630 (not counting copays) before your deductible will be met for the year.
ACA-Compliant Plans Count Copays Toward Your Out-of-Pocket Maximum
Although it’s rare to come across a plan that counts copays towards the deductible, all ACA-compliant plans count copays (for services that are consideredessential health benefits) towards yourannual out-of-pocket maximum, and there’s an upper limit in terms of how high your maximum out-of-pocket can be, assuming you receive all your care from medical providers who are in your health plan’s network.
As long as your plan isn’t grandfathered or grandmothered, your total in-network out-of-pocket costs can’t be more than $9,450 in 2024 (or $18,900 for multiple family members covered on the same plan).In 2025, these limits on out-of-pocket costs will decrease for the first time ever, dropping to $9,200 for a single person and $18,400 for a family.
Most health plans have out-of-pocket limits below those caps, so you may have a plan that has a much lower cap on how high your in-network out-of-pocket charges can be during the year. (Note thatOriginal Medicare—without supplemental coverage—works differently and does not have a cap on out-of-pocket charges.)
Most people don’t end up meeting their maximum out-of-pocket for the year. But if you do, it can be any combination of copays, deductible, and coinsurance that gets you to the limit. If you have numerous services to which a copay applies, you may end up meeting your out-of-pocket limit due solely to copays, without having to meet your deductible at all.
In that scenario, you wouldn’t have to meet your deductible for the year, even if you subsequently needed care later in the year for which the deductible would normally apply. That’s because the out-of-pocket maximum can be any combination of copays and/or deductible expenses, along with coinsurance if the deductible is met. If the out-of-pocket maximum is reached via copays before the deductible is reached, the rest of the deductible does not have to be paid.
For services that are subject to copays, it’s common for copays to continue to be charged until the annual out-of-pocket maximum is met. But for services that are subject to the deductible, you might find that you switch to paying coinsurance (a percentage of the cost) after the deductible is met but before the out-of-pocket maximum is reached.
(Note that if the plan also covers out-of-network care, that will have a separate deductible, and may or may not have a cap on out-of-pocket costs. Either way, the amount that has been spent on in-network care will not count toward the out-of-network deductible.)
Summary
As a general rule, copays do not count toward a health plan’s deductible. Copays typically apply to some services while the deductible applies to others. But both are counted towards the plan’s maximum out-of-pocket limit, which is the maximum that the person will have to pay for their covered, in-network care during the plan year.
2 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year.Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2025 Benefit Year. November 15, 2023.Additional ReadingCenters for Medicare and Medicaid Services.Affordable Care Act Implementation FAQs — Set 18.
2 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year.Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2025 Benefit Year. November 15, 2023.Additional ReadingCenters for Medicare and Medicaid Services.Affordable Care Act Implementation FAQs — Set 18.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year.Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2025 Benefit Year. November 15, 2023.
Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year.
Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2025 Benefit Year. November 15, 2023.
Centers for Medicare and Medicaid Services.Affordable Care Act Implementation FAQs — Set 18.
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