I'm a healthcare policy expert with a focus on insurance and out-of-pocket costs. It's important to understand how medical expenses are structured within health insurance plans, particularly when it comes to copays and their impact on out-of-pocket maximums.

Copays are fixed amounts that a policyholder must pay for certain healthcare services, such as doctor visits or prescription medications. These are typically set amounts that do not vary with the cost of the service received.

Out-of-pocket maximums, on the other hand, are the most a policyholder will have to pay for covered services in a plan year. Once this limit is reached, the insurance plan typically covers 100% of the allowed amount for covered services for the remainder of the plan year.

Starting in 2014, as per the healthcare reform, **copays must count towards the out-of-pocket maximum**. This means that every dollar paid as a copay contributes to the total out-of-pocket expenses for the year, and once the total reaches the out-of-pocket maximum set by the plan, the insurance company will cover the remaining costs for the year.

However, it's crucial to differentiate between copays and deductibles. A deductible is the amount a policyholder must pay out-of-pocket before the insurance plan starts to pay its share of the costs. Whether copays count towards the deductible is dependent on the specific terms of the insurance plan and the carrier. Some plans may have copays that apply towards the deductible, while others may not.

For example, if a plan has a $1,000 deductible and a $6,000 out-of-pocket maximum, and the policyholder has a $20 copay for a doctor's visit, the $20 copay would count towards the out-of-pocket maximum but not necessarily towards the deductible, depending on the plan's rules.

It's also important to note that there are exceptions to this rule. Plans that are grandfathered or grandmothered are exempt from certain provisions of the healthcare reform. These are plans that existed before the Affordable Care Act (ACA) and have not made significant changes to their structure, allowing them to avoid some of the new rules.

In summary, while copays generally count towards the out-of-pocket maximum as per the healthcare reform standards, whether they count towards the deductible depends on the specific insurance plan and carrier. It's always a good idea to review the Summary of Benefits and Coverage (SBC) provided by your insurance company to understand how your plan handles these costs.

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Starting in 2014, copays must count toward the out-of-pocket maximum. This standard is mandated by healthcare reform and applies to all plans, except grandfathered or grandmothered ones. However, it must be noted that whether or not copays count toward the deductible depends on the plan/carrier.Aug 18, 2014read more >>