Fact checked by Jim Lacy
Copayments, coinsurance, deductibles…. Health insurance could have a dictionary all its own. Copays are out-of-pocket fees that range from a few dollars for routine doctor visits to hundreds or even thousands for prescriptions or specialty care.
Copays emerged in the mid-20th century as employer-sponsored health insurance plans gained popularity. Initially, they were introduced as a modest way to ensure people contributed to their care while discouraging unnecessary use of medical services. Over time, rising healthcare costs have driven copays higher, with amounts varying based on the type of service, provider network status, and insurance plan.
Critics argue that high copays deter necessary care, especially for low-income families. However, insurers and policymakers view copays as a tool to balance costs and encourage personal financial responsibility.
Understanding your copay structure is key to managing healthcare expenses.
Medicare copays and coinsurance follow a more predictable structure, says Robin Dawson, an independent Medicare broker in Park Ridge. The private insurance landscape is far less predictable. “In the private insurance world, you might see a copay of $1,000 just to walk into an emergency room on an Affordable Care Act plan. Meanwhile, on a group insurance plan, that same ER visit might only cost $250,” Dawson says.
Navigating healthcare costs is all about finding the right balance between coverage and access to care. “Everything has trade-offs,” she says, “no matter what type of insurance you have.”
Originally published in the Spring/Summer 2025 print issue.
Catherine Gianaro, a freelance writer and editor based in Chicago, has written about healthcare and higher education for more than three decades. With 90-plus awards in communications, she is well-versed in storytelling.
