A copay is a flat fee for a specific service, set by the plan: $25 for a primary care visit, $50 for a specialist, $10 for a generic prescription. You pay it at the counter, the plan pays the rest.
It differs from coinsurance, which is a percentage rather than a fixed amount, and it behaves differently against the deductible depending on the plan — some services are copay-first, others only after the deductible is met.
In New York, copay levels are the practical difference between the programs:
- Medicaid — no copays for most services.
- Essential Plan — no premium, no deductible, and copays that are either zero or very small depending on income tier.
- NYC Care — no copays at or below 200% of the federal poverty level; modest sliding-scale amounts above it.
- Marketplace plans — copays vary by metal tier, and the plan documents are the only reliable source.
The trap: an emergency room copay applies on top of whatever the facility bills. A $150 “ER copay” is not the price of the visit.
Also called: copayment, co-pay. Reference: Copay on Wikipedia — general definition, not New York specifics.
More in Glossary of health coverage and billing terms
- Balance billing — When a provider bills you for the gap between its charge and what your plan paid.
- Federal poverty level (FPL) — A federal income benchmark, updated each January, that decides eligibility for most health programs in New York.
- Deductible — The amount you pay yourself each year before the insurance plan starts paying its share.
This page explains how the system works. It is not medical advice. More.