Out-of-Network Copayment

An out-of-network copayment is a fixed dollar amount you pay for a covered service from a provider who isn't in your plan's network. It's typically higher than the copayment you'd pay for the same service from an in-network provider.

Not all plans use copayments for out-of-network care; many use coinsurance (a percentage) instead. But when a plan does have out-of-network copays, they're noticeably more expensive. For example, your plan might charge a $30 copay for an in-network primary care visit but $75 for the same visit out-of-network.

Like out-of-network coinsurance, copayments for out-of-network care come with additional financial risks. The copay only covers a portion of the allowed amount; if the out-of-network provider charges more than what your plan considers reasonable, you could be balance billed for the rest. And out-of-network copays may not count toward your plan's out-of-pocket maximum.

HMO and EPO plans generally don't cover non-emergency out-of-network services at all, so there would be no copay; you'd owe the full amount. PPO and POS plans are more likely to have out-of-network copay or coinsurance structures.

Before seeing an out-of-network provider by choice, always call your insurance company to understand what you'll owe. The copay alone doesn't tell the full story; ask about balance billing exposure and whether the costs count toward your maximum.