I have individual health insurance and have met my out-of-pocket maximum due to a surgery earlier this year.

I saw my (in-network) PCP this week and was still charged the regular $30 copay. Should that have been waived, will I get a check back, or does it not matter that I've met the "maximum" and still have copays for covered expenses?

  • 4
    Most likely, the Dr's office just charges you whatever copay amount is written on the card. They aren't able to tell how much you spent on healthcare so far this year. When you get the EOB, check it and see if the insurance company thinks you had a copay. If they don't bring the EOB to the Dr and ask them for a refund.
    – lzam
    Commented Jun 27, 2017 at 13:45
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    When did you buy this plan? Is it grandfathered?
    – quid
    Commented Jun 27, 2017 at 15:32
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    @quid I had the same question. Are there still grandfathered plans out there? The rules changed back in 2014.
    – stannius
    Commented Jun 27, 2017 at 15:55
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    @stannius, there are grandfathered plans out there still, they're rare, but out there. It was really common for the maximum to really be a "coinsurance maximum" excluding copays and sometimes the deductible.
    – quid
    Commented Jun 27, 2017 at 16:55
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    My doctor's office collects the copay on the card, as @lzam suggested. Once I've met my out-of-pocket max, I just tell them I've hit it, and they're happy to accept $0. If I'm wrong about it, they'll send me a bill.
    – ceejayoz
    Commented Jun 27, 2017 at 17:16

2 Answers 2


Generally speaking, under an standard Obamacare plan, you should not have to pay any copays or coinsurance on any essential benefits once you have met your out-of-pocket maximum (Obamacarefacts.com).

In practice, however, there are a few complicating factors:

  1. Did the money you spend so far count towards your out-of-pocket maximum? If you payed for uncovered out-of-network care, or other non essential benefits, your insurance company may not count that towards your maximum out of pocket expenses.
  2. Have all the claims been processed? While you often pay your co-pay at the time of service, the insurance claims process is much slower. Your insurance company may not have caught up with all of your bills, and so have not yet calculated your total out-of-pocket costs so far.
  3. Is your insurance company making a mistake? Be sure to review your EOBs and bills and make sure everything seems to match up and make sense according to your insurance contract. Insurance companies can make mistakes, and those mistakes usually aren't in your favor (at least that is my personal experience). Keep an eye out for possible mistakes, and call your insurance company if you think you have found one.
  4. Even if your insurance company doesn't think you owe a co-pay, your doctor doesn't know that: Your doctor's office probably just bills whatever co-pay they see written on your card. It is unlikely that they can tell that you already met your maximum-out-of-pocket until the claim is processed by your insurance company. If you know you met your maximum-out-of-pocket already, just explain that to the receptionist (or whoever does the billing) when they ask you for your co-pay.

As for unnecessary co-pays you already payed: In my experience, the insurance company will pay the claim without applying a co-pay, and leave it up to the doctor to refund your co-pay. However, you should call your insurance company to verify this. If they do tell you to get a refund from your doctors office, wait until you get the EOB for the vist (which should show you owe no copay) and bring it in to your doctor's office when you ask for a refund.

  • As both answers said, it is probably just that the Dr's office didn't know not to bill. I'll wait a few weeks to see if the bill shows on the insurer's site and includes the copay or not. Also, I might get a check back by then.
    – Gary
    Commented Jun 27, 2017 at 18:52
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    They may also be betting that the 30 bucks won't be worth making a big stink over.
    – corsiKa
    Commented Jun 27, 2017 at 23:28

Your best bet is to call your insurance provider and ask. Typically copays do not count towards the deductible but do count towards the Out Of Pocket Max. It's probably the case that the PCP does not know that you hit your OOP max and charged the copay as your insurance card instructs. I expect you will receive a reimbursement check from your insurance company, or from the PCP if the insurance reimburses them directly.

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