What services an office visit co-pay covers is a very common point of confusion for Texas consumers. An office visit co-pay establishes a fixed, predetermined price for the consultation with a physician. Many consumers believe that whatever services are received during the office visit are covered by the predetermined fee, which is typically either $25, $30 or $35, depending on the plan and the carrier. The predetermined charge of a plan with an office visit co-pay differs from a plan with no office visit co-pay.  The average consultation with a primary care physician in Texas will cost between $125 and $150. The office visit in almost all cases only pays the cost of the consultation and examination by the physician.  Other services, such as lab, x-ray, injections or supplies are not paid by the office visit co-pay benefit.  

The benefit of the office visit co-pay to Texas consumers is that the physician’s charge for the examination and consultation is established by the insurance carrier before the service is received. The office visit co-pay will apply to a general practitioner or a specialist. 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.  

For example, if a policyholder seeks medical attention for a skin condition such as poison ivy, the doctor will examine the patient and may recommend a steroid injection. The examination and consultation will be subject to the office visit co-pay benefit, but the steroid injection will not be included. The steroid injection will qualify for the negotiated discount and will be applied to the deductible. If the deductible has been met, the expense will be subject to the plan’s coinsurance rate. 

If a policyholder has a plan with no co-pay benefit and the physician is in-network, the office visit will be subject to the negotiated rate, which can be 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 plan without the co-pay benefits.

However, it is important to understand that plans with an office visit co-pay will have higher premiums than similar plans without an office visit co-pay. Texas consumers should compare the difference in the annual premium cost between plans that offer an office visit co-pay benefit and plans that do not offer the office visit co-pay benefit. If the policyholder has historically visited physicians on a limited basis, the higher premium for a co-pay plan may not be justifiable. 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 without the co-pay benefit, which produces a factor of 7.5.  A simple analysis would indicate that if the policyholder expects to visit the doctor less than 7 times during the year, the individual will spend more on premium than the policyholder received in benefits.

The office visit co-pay benefit can be justified not necessarily from an economic analysis but from the belief that the co-pay benefit improves an individual’s overall health by reducing the cost barrier of treatment.  The belief is that with a predetermined office visit cost, Texas consumers are more likely to seek treatment and avoid more costly serious conditions. Texas consumers should always analyze how much benefit will be received by an established rate for the doctor’s advice when determining the most appropriate health insurance plans to purchase.  


Stateside Insurance Services, since 2003, has focused on providing comprehensive health insurance information, responsive customer service and expert industry knowledge for Texas consumers. Stateside has annually been recognized by health insurance carriers and the Health Insurance Marketplace as a Top Producer in Texas.

Whether the health insurance policy is for an individual, family, small business or supplemental Medicare coverage, Stateside dedicates the time, and our deep industry expertise, to ensure our clients have identified the best health insurance plan for their specific needs. 

Stateside is available to answer any general questions regarding your coverage options, can provide a subsidy determination, and even assist in creating and submitting online applications for ACA compliant plans during an Open Enrollment or throughout Special Enrollment periods. 

Stateside can be contacted either by phone (866) 444-3332 (toll free) or by email at info@texasplans.com.  Our Telephone Appointment System can be accessed through:

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By using the Telephone Appointment System, clients can take advantage of scheduling a health insurance discussion when convenient for their schedule. During Open Enrollment phone appointment availability is expanded to include extended hours and weekends.