Changing copays: What to know.
Refresher: Copays are predetermined rates you pay for health care services, collected at the time of service.
It’s not unusual for the cost of a CT scan (or just about any common test) in a hospital setting to be considerably higher—sometimes even twice as much—than in a doctor’s office or community-based setting.
What is unusual is having a health plan that not only ditches deductibles, but gives members the tools to see these copays upfront.
Then again, there’s nothing “usual” about the Surest health plan.
Unlike traditional plans, Surest members can shop and compare care options before they schedule an appointment—a lot like how we’re used to shopping online. Without the ability to check copays in advance, you could be overpaying for care.
“Surest motivates people to shop for care,” says Robert Harder, senior director of data analytics at Surest. “It changes behaviors.”
The making of a copay (and why it can change)
Price transparency helps Surest stand out, but it’s the forward-thinking copay methodology that takes it to the next level. Once a year, copays are recalculated for the providers, hospitals, and clinics Surest evaluates. Copays might go up, might go down, or might stay the same from one plan year to the next—but will not go outside the established price range for a given service. Because of these changes, it’s important to check copays during open enrollment, particularly for providers you’ve seen in the past. If you check copays during the plan year, you’ll see what they are at that moment—but they might not stay that way when copays are recalculated. Checking during open enrollment is a great way to verify (and avoid surprises).
Why do copays change?
Reason one: Your employer’s benefit design changes.
Employers can tailor their health plans to suit their business needs, budget, and employee preferences by adjusting factors like copays, covered services, and plan benefits. To manage costs, some employers may opt for more comprehensive plans with lower out-of-pocket expenses, while others may choose more basic plans with higher cost-sharing requirements. This flexibility allows employers to balance their financial constraints with the needs of their employees.
Reason two: A health care disparity.
When compared to other developed countries, health care in the United States is nearly twice as costly. This disparity is often attributed to high administrative costs, rewarding quantity vs. quality, and an overall lack of transparency, contributing to wide-ranging health care prices.
Reason three: Surest is working hard to change the system.
Surest has their own method for setting copays. It’s a collaboration across inventory, search, and health teams, explains Matt Chock of Surest.
For one, providers are evaluated on services they offer using that provider’s historical effectiveness and cost efficiency performance data. This results in what Surest calls a Care Rating for a particular service.
The goal of Care Ratings is to help explain to members, in the Surest experience, the link between copays and historical provider value.
Some services are variable—meaning they can vary across providers for the same service (a hospital vs. a clinic, for example). Some services are fixed—meaning copays are the same for all providers for the same service.
Effectiveness
The effectiveness of a provider measures historical frequency of trying proven treatments before surgery, the success of those treatments, avoidance of complications and repeat procedures, infection prevention, whether emergency services were needed after treatment, rates of readmissions, etc.
Cost efficiency
The cost of getting care matters. Cost efficiency measures whether a provider delivered appropriate, effective care in an economical way, including the use of in-network, lower-cost sites of care for tests and treatments.
For variable copays, a provider who scores higher gets a higher Care Rating—and a lower copay—for that service.
When members understand the rationale behind why a copay is higher or lower, they’re equipped to make informed decisions—and those decisions collectively have the power to change the landscape.
Need a quick copay check? Pull up the Surest app or sign in to your member account before scheduling care.