A co-pay is a fixed cost-sharing amount at point of service under health coverage.
How it works
The policy states specific services and amounts, for example:
- office visit copay,
- specialist visit copay,
- emergency service copay.
Co-pays make utilization expectations visible and predictable for both members and plans.
Claims and utilization logic
Claims systems apply co-pay rules automatically against provider claims. The remaining amount (after co-pay and possibly deductible) is processed under plan benefits, and out-of-pocket trackers are updated.
Scenario
A policy provides a $25 primary-care copay and a $60 specialist copay. Two visits in one month are processed: the first at $25, the second at $60, each credited separately according to their service type.