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When
Texas consumers research health insurance
options, the office visit co-pay is one
benefit that is typically a priority when
determining plan selection. An office visit
co-pay benefit has been considered a
requirement for employer sponsored group
coverage, which leads consumers to include
the benefit when evaluating individual or
family coverage outside of the workplace.
An office
visit co-pay establishes a fixed,
predetermined price for the consultation
with a physician. In almost all cases, the
office visit co-pay only pays the cost of
the consultation. Other services, such as
lab, x-ray, injections or supplies are not
paid by the office visit co-pay benefit.
The predetermined fee is either $25, $30, or
$35 depending on the carrier. Health
insurance plans can provide the office visit
co-pay benefit either with or without a
limit in the number of office visits.
The
benefit to the consumer is that the fee for
the physician’s consultation is known before
service is received. Instead of the office
visit charge varying based on the scope of
the consultation or specialist, the office
visit charge will always be the same.
The
office visit co-pay provides a significantly
discounted charge as compared to plans with
no office visit co-pay. In Texas the
average consultation with a physician will
cost between $125 and $150. If a policy
holder has a preferred provider organization
(PPO) plan with no co-pay benefit and the
physician is in-network, the office visit
will be subject to the PPO discounted rate,
which is typically between $70 and $80. The
office visit co-pay — $25, $30 or $35
depending on the carrier and the plan —
offers even deeper discounts than the PPO
plan without the co-pay benefits.
It is
important to remember that Texas health
insurance plans with an office visit co-pay
will have higher premiums than similar plans
without an office visit co-pay. The cost
benefit of the office visit co-pay is
realized by comparing the annual cost
between the total premium cost and office
visit cost of the co-pay plan and the total
premium cost and office visit cost of
coverage that does not provide the co-pay
benefit. If you assume a premium difference
between the coverage that includes an office
visit with a co-pay is $50 more per month in
premium than coverage that provides no
office visit co-pay. The $600 annual cost
difference of the office visit co-pay plan
is divided by the discounted office visit
rate of $80 which produces 7.5. The
comparison states that if the policy holder
expects to visit the doctor at least 7 times
during the year, the higher office visit
co-pay premium can be justified from an
economic standpoint. However, if the policy
holder visits the doctor less than 7 times,
the individual spent more on premium than
the policy holder received in benefits.
An
intangible benefit of the office visit
co-pay is the belief that it promotes better
health care by reducing the obstacle of cost
when seeking treatment. With a
predetermined co-pay rate, Texas consumers
are more likely to address health issues
before those conditions become more serious.
An office
visit co-pay benefit are very popular, but
it is important to understand their impact
on premium cost and on the tangible benefits
the provide Texas consumers.
Individual - Family
Texas Health Insurance
Small Business Health
Insurance
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