What is copayment in health insurance

We could define a copay as a small amount of money that must be paid for a medical service. If we go to the doctor for a consultation or blood test, we will have to pay a small amount.

This amount will be added to the premium that is paid monthly. The big difference with insurance without copay is the cost of the premium, which is much cheaper.

Both for the user and the companies, this option is becoming more advantageous every day. In the first place because for the user it is cheaper health insurance . But besides that is the fact that it generates an awareness about the use of the service and a responsibility. The user knows that the more he uses the health insurance, the more he will have to pay. Thus, unnecessary trips to the doctor are avoided.

If what you are looking for is quality medical care, but we are not constant users, it is an ideal option. The premium will not increase but we can enjoy all these services with an excellent medical chart.

Even so, we must seek advice on what the cost of the copay will be, since it generally increases with its use.

What is the deductible and copay?

Both the deductible and the copay represent an economic part that we will have to take care of. But they are different from each other. Let’s see how they differ.

What is the deductible in an insurance policy?

The deductible is a fixed amount of money that must be paid before the insurance covers the rest of the expenses. This deductible can vary in amount depending on the type of insurance.

The higher the deductible, the lower the premium. The same if the opposite happens.

How does the health insurance deductible work?

The deductible varies a lot from one insurance to another, for this reason it is good to be informed in advance. The operation is very clear: the user pays that certain amount and the insurance will take care of the rest.

Depending on the conditions of each insurance, the payment can be annual, monthly or in each of the uses. The latter is usually the most used formula.

Difference with copay

The copay is similar to the deductible. As we have already seen, it is the amount of money that is set and paid each time we need to use the insurance.

The main difference is that the copay is usually a smaller amount and also, in these cases, that copay is applied per visit. The deductible can be applied monthly or annually.

What does no coinsurance mean?

Coinsurance or reimbursement is a percentage that represents the cost that must be paid by the user. Subsequently, the insurance will take care of the rest of the medical expenses.

The percentage can be very varied among themselves from 80/20, 90/10 or 50/50. In these cases, if for example the percentage is 80/20, what it means is that the insurance will cover 80% of the expenses. The user will then have to pay the remaining 20%.

Generally, if you have coinsurance, you also have a deductible, but it depends on each insurer.

When health insurance does not have coinsurance then the above does not apply.

What is health insurance without copay?

Given everything we have seen, it is easy to know what health insurance without copayment is. It means that when we go to a medical consultation, there will be no need to make any payment. All this will be covered from the payment of the monthly insurance premium.

It is very common to see dental insurance without copay and of course medical insurance with extra services. Of course, what happens in these cases is that the premium to pay is much more expensive than without a copay.

The recommendation will be that those people who make greater use of medical services take out this insurance. Whether it is an exceptional situation or something chronic, you will end up paying for insurance without a copay.

For those who want to have the policy as a precautionary method and do not plan to go regularly, then the copay will be better.

Health insurance without copays without deficiencies

Beyond the concept of copay or no copay, there is another concept to consider that is the lack.

The gap is that period where some coverage will not be active. That period runs from the moment you take out the insurance until the day it is determined that you can use it. Generally, these deficiencies are included for exams or operations that are very expensive. For example, for a transplant or childbirth.

It should be noted that not all insurances have a grace period, although there are very few. Everything will depend on each coverage you have. Even so, you have to know that this grace period by law is eliminated when it is something urgent.

There are two very specific cases where the grace period can be eliminated. One of them, as we indicated, is when there is an emergency. This is determined by the General Directorate of Insurance and Pension Funds in Law 50/80 of Article 103.

It is defined that something urgent is that which, if not done, endangers the life of the patient.

The other case where the option to eliminate the deficiency appears is when you come from another health insurance. This will depend on your conditions but every day the elimination of the deficiency is applied in those cases. Thus, the transfer from one company to another can be offered more, knowing the user that they will not have a gap to fulfill.

Type of deficiency in medical insurance

The grace period in medical insurance is determined in the General Conditions of the policy. Each one is different so it can vary from one case to another. In general terms, these are the terms used:

  • Intervention without hospitalization: 3 to 6 months.
  • Diagnosis with high technology: 3 to 4 months.
  • Highly complex clinical analyses: 3 to 6 months.
  • Pain medicine: 3 to 6 months.
  • Childbirth and postpartum: 6 to 10 months.
  • Transplants: 12 months.
  • Assisted reproduction: 24 months.
  • Interventions with hospitalization: 6 months.

All the services that are not specified in the deficiency part can be used immediately.

What health insurance to hire

It is normal that with all the existing options you have doubts about which is the best insurance to hire. It is not only about choosing the insurance company but also the contracting modality.

One of the big reasons why people want to buy health insurance is for the best care. The speed with which it complies is greater than that of Social Security. This is because companies often have their clinics, labs, and call centers.

Advantages of private insurance

One of the greatest advantages is time, not having to wait a month or more for medical attention.

On the other hand, specialists can be accessed directly without going through a family doctor. Once again, this results in an overall time savings.

We can also choose the doctor who treats us and the hospital if it is within the medical insurance plan. In some cases, even if it is not from the medical list, the consultation will be covered.

In case you have a hospital admission, the companions have greater benefits and comforts.

Health insurance coverage

Whether you choose insurance with a copay or without a copay, the coverages are usually the same. In general terms, these are the existing medical coverages:

  • General medicine.
  • Pediatrics.
  • Childcare.
  • Nursing.
  • Hospitalization.

There are also usually other types of alternative or special services such as acupuncture, homeopathy or the possibility of having a second medical opinion.

It should be noted that there may be some coverage that is excluded from health insurance. Generally this is due to pathologies that are had before hiring and that have not been declared.

In other policies, it is added that injuries that occur in high-risk sports will not be covered. For that there are special insurance for professional athletes.

Plastic surgeries that are for cosmetic reasons are also excluded from coverage.

Medical coverage abroad

The vast majority of private medical insurance includes coverage abroad.

In these cases, they will tell you to call a specific telephone number where you will be told which center to go to. Depending on each case, the patient may have to bear the expenses and then receive a reimbursement.

You have to be very clear here what the maximum amount of coverage abroad is. This is important because there are cases, like the United States, where medicine is very expensive.

Even so, for a trip abroad it is always recommended to have specific travel insurance for each activity.

How to choose the best health insurance with or without copay

The choice is quite difficult. That is where it is recommended to have expert advice to see which is the best insurance in our case.

Some insurers have special plans for the self-employed while others have it for the whole family.

If you want to be treated by a specific doctor, check beforehand that it is part of the insurance medical chart. Otherwise you have to have the possibility of reimbursement for another medical opinion.

If you like to be treated in a specific hospital, we also recommend that you review the policy. Not all hospitals have agreements with the same insurers.

It may be that your decision, beyond that, is defined by the extra services that they offer you, such as dental insurance. Be that as it may, you have to read the covers very well and know them in depth.

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By Michael Caine

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