By Mick Constantinou
September 27th, 2021


Consumers are becoming savvier in looking for ways to reduce their health care costs.  As the average major medical consumer does their research, and takes their utilization habits into consideration, many are finding that a plan without a PCP copay costs less annually and provides more control over health care spending than a traditional copay plan.


Below are considerations when selecting the right plan design for your needs:


  • Copay plans typically have higher monthly premiums — $70 to $120 higher for an individual depending on the carrier and design features — because consumers are paying extra for the privilege of unlimited discounted doctor visits, not just for themselves, but for everybody else with that copay plan.


  • Preventive (Wellness) visits recommended under the Affordable Care Act are covered 100%, including copays and office visit charges.


  • The average copay is $40 vs. the average network-discounted office visit charge is approximately $120.


  • The pandemic’s impact on the delivery of health care increased telemedicine utilization (virtual visits) by 4000% between 2019 – 2020, according to Humana, and most carrier plans are offering this as a $0 or reduced-dollar copay.


According to the Centers for Disease Control and Prevention, the average person has approximately two non-preventive doctor office visits per year.  With two non-preventive office visits per year, a consumer would pay $240 in annual office visit charges with a no-copay plan vs. $80 in annual copays with a copay plan — a savings of $160 with the copay plan.  However, with that copay plan, consumers are paying $840–$1,440 more per year in premiums.  Based on this scenario, it does not make financial sense to pay up to $1,440 to save $160.


NOTE:  The financial comparisons, assumptions, and averages above are based on a holistic look at the current carrier market and do not represent specific rates for a particular carrier or market.  The calculations are utilized as an example and to illustrate the thought process and analysis a consumer should do on their own and/or through their advisor to determine the strategy that best meets their needs.



DISCLAIMER: This update is general in nature.  The information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice, financial advice and/or the advice of a licensed insurance or certified human resource professional.


 © SandStone Insurance Partners 2021

Leave a Reply