Copayment in health plans: what it is and how it works

The term copayment comes up a lot when we are researching health plan options. Although many people associate it with an extra fee, in practice it is a cost-sharing model that can significantly reduce the monthly premium, as long as it is well understood and suited to the member’s profile.

This article explains what copayment in health plans is, how it is calculated and what rules are set by the ANS (Brazil’s National Supplementary Health Agency) and current legislation.

What is copayment in health plans?

Copayment is the amount paid by the member after using certain healthcare services, such as consultations, tests or therapies, according to rules previously defined in the contract.

Unlike the monthly premium, which is fixed, the copayment is variable and depends on actual use of the plan. It does not replace the monthly payment but supplements the funding of the services used.

In practice, there are two basic plan models:

• Plan without copayment: a higher monthly premium, with no additional charge per procedure.

• Plan with copayment: a lower monthly premium, with additional amounts charged according to the use of services.

This model is widely used in both individual and corporate plans as a way to balance care costs.

How is the copayment calculated?

The copayment calculation varies according to the contract signed with the health plan, but it generally follows two main formats:

Percentage of the procedure

The member pays a percentage of the cost of the service.

Example: if a consultation costs the plan R$ 100.00 and the copayment is 20%, the amount paid will be R$ 20.00.

Fixed amount per event

There is a predefined fee, regardless of the actual cost of the procedure.

Example: R$ 30.00 per consultation or R$ 15.00 per simple lab test.

In both cases, the rules must be clearly described in the contract, including which procedures are subject to copayment and which are exempt.

Is copayment provided for by law?

Yes. Copayment is allowed under Brazilian regulations, as long as it respects the principles of transparency and consumer protection.

Among the most relevant points are:

• Clear, prior information: percentages, fixed amounts, limits and chargeable events must be expressly stated in the contract. Otherwise, no copayment amount can be charged.

• Hospital stays: there is generally no percentage copayment on the total value of a hospital stay. When there is a charge, it is usually a fixed amount per event or per day, to avoid unpredictable costs for the patient.

• Exemptions: prevention programs, chronic disease follow-up, prenatal care and other strategic services may be exempt from copayment, depending on the health plan’s policy.

These rules seek to balance rational use of the plan without compromising access to care.

Is there a limit on copayment charges?

Yes. Normative Resolution No. 465/2021 of Brazil’s National Supplementary Health Agency (ANS) establishes that the copayment cannot exceed 50% of the cost of the consultation or procedure.

The legal and regulatory principles underlying this limit assume that the copayment:

• cannot prevent the member from accessing treatment;

• must respect criteria of reasonableness and proportionality;

• must be clearly disclosed before the plan is purchased.

In practice, many health plans adopt monthly or annual copayment caps, especially in corporate plans, as a financial protection mechanism for members during periods of heavier use.

Is copayment worth it?

The choice between a plan with or without copayment depends directly on the care profile of the member or of the covered population.

Copayment and conscious use of the plan

One of the main goals of copayment is to encourage the conscious use of care resources. When there is a cost associated with use, however small, the following tends to occur:

• fewer unnecessary consultations;

• less repetition of tests without a clear clinical indication;

• fewer missed appointments.

From a systemic point of view, this behavior contributes to the sustainability of private healthcare, reducing inflationary pressure on care costs and, consequently, on annual premium adjustments.

Conclusion

Copayment in health plans should be seen neither as a villain nor as a universal solution. It is a cost-sharing mechanism that can be advantageous for some profiles and disadvantageous for others.

For members who use the plan occasionally or companies seeking greater cost control, copayment can be an efficient alternative. For people with chronic diseases or a frequent need for care, plans without copayment tend to offer greater financial predictability.

A careful analysis of the contract, combined with an understanding of the usage profile, is essential to avoid surprises and make more informed decisions.

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This article is for information purposes only and does not replace a careful reading of the health plan contract or of the current ANS rules.