A copay is the set fee you pay at every medical session, including therapy.
When you see a therapist who is in-network with your insurance plan, you pay them a copay at each therapy session. Then, your therapist sends a claim to the insurance company to receive the remainder of the fee they're owed.
Let’s say your therapist’s session fee is $100. If your copay is $25 per session, that’s the rate you are responsible for paying every time you have an appointment.
Your therapist gets paid the remainder of the session fee, $75, by the insurance company.
How does my deductible affect my copay?
If you have a deductible, your copay only applies after your deductible has been met.
Do note that any medical expense, such as a doctor's visit or medication prescription, contributes to reaching your deductible.
For example, if you have a $6,000 deductible and you haven’t had any other medical expenses yet in the year, you are responsible for paying up to $6,000 in therapy session fees out-of-pocket before your standard copay applies. Alternatively, if you’ve spent $1,000 in appointment-related fees at your ob-gyn’s office, you’ll have $5,000 left of your $6,000 deductible.
You pay the therapist’s full fee at every session until you've met your deductible amount.
When you have paid enough in medical costs that the sum of costs equals your deductible, it often referred to as "meeting your deductible."
Do I have a copay for out-of-network therapists?
Although there are no copays when you use a doctor or facility that is out-of-network, you are responsible for paying a percentage of the total bill – the coinsurance.
This is usually much higher than the in-network copay amount.
So copays only apply to in-network therapists?
Yes. If a therapist is “in-network” with an insurance company, they have agreed to accept the rate an insurance company is willing to pay per session.
Again, you pay them a set portion of the session fee, or “copay” after each session, and the insurance company pays the remainder.
Is a copay always the cheapest option?
No. If you have good out-of-network benefits, your insurance company may reimburse you as much as 80% of each session fee, depending on your plan and the therapist’s rate.
This means that in some situations, using your out-of-network benefits can actually be more affordable or comparable to your standard copay to see an in-network therapist.
How do I figure out what my copay is?
The amount of your copay depends on the details of your specific plan. You can find this amount on your Explanation of Benefits (EOB), listed as “allowed amount.”
If you’re unsure about the details of your specific coverage, contact your insurance company. You can search on their member services page, or call the number on the back of your insurance card.
Find in-network and out-of-network therapists on Zencare.co!
If you need help navigating health insurances or using out-of-network benefits, visit our guide to using health insurance for therapy, or contact our team at firstname.lastname@example.org.