What is a variable copay?

Even when you’re doing your part to stay healthy and feel your best, trying to calculate the cost of your health care can leave you with a headache. Traditional health insurance isn’t always transparent. But innovative variable copay plan models (sometimes called dynamic copay plan models) offer a more modern approach to health insurance that puts predictability and value first.

We’ll explain what a variable copay is, how it differs from the copay plans you’re used to and how copay-only plans, like HealthPartners Simplica, are helping make health care simple and affordable.

Copays help keep insurance affordable for both you and your insurance company

A copay, or copayment, is a fixed cost a health plan member is expected to pay out of pocket for in-network covered health care services (some plans have out-of-network copays but it’s less common).

Copays are a form of cost-sharing that makes coverage more affordable for both insurance companies and plan members by dividing up health care costs. They help keep premiums (the amount you pay each month for health care coverage) lower by ensuring plan members use health services responsibly. This helps insurance companies avoid unnecessary claims so they can keep their costs down and pass those savings on to you.

Do you have to pay a copay every time you go to the doctor?

Yes. If your health plan has a copay, you pay it each time you visit the doctor or fill a prescription. But the amount you pay varies depending on what copay model your plan has. There are two types of copay models – variable copay (or copay only) and fixed copay.

The difference between fixed copay and variable copay models

There are two main differences between fixed and variable copay plan models. The first is whether the copay amount you pay before a service stays the same or varies depending on the type and quality of care. The second is whether the plan has a deductible and/or coinsurance.

A fixed (traditional) copay is what most people think of when they hear the term copay

These plans offer coverage through a series of fixed copays and coinsurance rates you pay either before or after meeting your deductible for things like:

• Primary care
• Specialist visits
• Emergency or urgent care
• Prescriptions

It’s not always easy to tell the difference between copays and coinsurance, which can make it harder to figure out what you’ll pay ahead of time for certain medical services – unless you check your plan details or talk to someone at your insurance company.

Variable copay plans offer a more modern approach

These types of plans have no deductible and no coinsurance for in-network care, so members can see what they’ll pay ahead of time for every service. Copay costs for these plans vary based on things like chosen provider, cost and quality of care.

How copay prices are determined

Different plans require different copay amounts for services, but:

Traditional copay prices are set by insurance companies

These amounts are based on where funds are assigned within a plan, which can change based on the plan type or what additional benefits are offered. For example, a copay paid for a primary care visit could be between $20 to $40 depending on your plan, while going to a specialist could range from $50 to $100. But the cost would be the same no matter who you see in your plan’s network.

Copay-only and variable copays have value-based pricing

Out-of-pocket costs for variable copay plans can vary based on things like chosen provider, cost and quality of care. Your copay is lower when you choose care providers and locations that:

• Deliver higher-quality care (based on provider ratings, which we’ll go into more detail on below)
• Charge a lower total price for the same or similar type of service

Your copay also depends on the type of care provider you’re seeing (such as primary care or specialist), and the type of location (such as a clinic or hospital).

For our copay-only plan, Simplica, all of these factors together determine provider ratings.

How provider ratings are determined

Provider ratings are determined by how well providers care for patients. These ratings are based on real results, like how well patients recover, how safe the care is and how people feel about their experience. Choosing a top-rated provider means better care for you at a lower cost.

There’s no complicated math, just a simple, clear, flat price for everything. You’ll see your cost up front, so it’s easier to choose care that fits your needs and your budget.