Copays in Health Insurance: How They Work, How Much You Pay, and When They're Waived

A copay/deductible (השתתפות עצמית) is the part you pay out of pocket for a service your private insurance covers — sometimes a fixed amount per visit, sometimes a percentage of the cost. The amounts themselves are written in your policy, but they're scattered across different sections and it's not always clear what you'll actually pay. In this article we'll explain how to read the copay clauses in your policy, what's typical for consultations, treatments, surgeries and medications — and when you don't pay at all.

What a copay is and why it exists

When the insurance company covers a medical service, it doesn't always pay the full cost. The copay is the amount left to you: a fixed payment to the doctor for a consultation, a percentage of a medication's price, or the gap between what you paid and the reimbursement you received. The mechanism exists in most health policies, and it's one of the things that separates one plan from another: a cheaper policy will usually come with higher copays, and vice versa.

It's important to distinguish between the copay in your private insurance and the one in the shaban (שב"ן — your health fund's supplementary insurance). In the shaban there is usually a copay on private surgeries, typically a percentage of the surgery's cost. In private policies the picture is different, and depends on the plan and on how you use the service.

Percentage or fixed amount: the two forms of copay

In most policies you'll meet one of two forms:

• A fixed amount — for example, a uniform payment for every consultation with an in-network (הסדר) specialist, regardless of the doctor's rate. This is the common form for services provided through the company's network providers.
• A percentage of the cost — for example, 5% to 15% of the price of a medication not in the health basket, per month of treatment. Here the actual amount depends on the price of the service, so it's important to check whether there's a cap.

There's also a third, less visible form: partial reimbursement. If the policy reimburses, say, 80% of an expense up to a cap, the 20% left to you is effectively a copay — even if the policy doesn't call it that.

Copays by type of service

Consulting a specialist. With an in-network doctor you usually pay a fixed amount directly to the doctor, on the order of about 100 to 200 NIS per visit (the rates published by the large insurers hover around this range, and an online consultation is usually cheaper). With a private doctor outside the network you pay the full fee and submit a reimbursement claim — and whatever wasn't reimbursed stays with you.

Ambulatory treatments and tests. In ambulatory coverage (tests, diagnostics, treatments that aren't surgery), the usual mechanism is a percentage reimbursement up to a cap per insurance year. The percentage and the cap vary a lot between policies, so this is where checking your specific clause matters most.

Surgeries. When you operate through one of the company's in-network surgeons, there is usually no copay, or a low one. In mashlim shaban (משלים שב"ן) policies — the type that became the default after the 2024 reform — you first use your health fund's shaban, and the private policy usually covers the gap, including reimbursing the copay paid in the health fund. A private surgeon outside the network may leave a significant gap at your expense.

Medications outside the health basket. Here the copay is usually monthly — a percentage of the drug's price (typically 5% to 15%) or a fixed amount per month of treatment, sometimes with a cap. In some policies the copay is waived once the monthly cost passes a certain threshold. We covered this in more depth in the article on drugs outside the health basket.

Caps: the small detail that changes the math

A copay clause doesn't end with a single number. It's worth looking in the policy for:

• A copay cap — is there a maximum amount you'll pay, for example a monthly cap on the copay for an expensive drug.
• A reimbursement cap — the maximum amount the company will reimburse per service or per insurance year. Anything beyond the cap stays with you.
• A quantity limit — for example, the number of consultations or treatments per insurance year.

Two people with "the same coverage" can pay completely different amounts because of these differences, which is why a real comparison is done against the policy wording — not against a marketing page.

When there's no copay at all

There are a few situations where you usually won't pay a copay:

• Surgery with an in-network surgeon — in many network plans the surgery is fully covered with the contracted provider.
• An especially expensive drug — in some medication policies, once the monthly cost passes a threshold set in the policy, the copay is waived; and some policies exempt certain drugs upfront, such as oncology treatments.
• A mashlim shaban policy "without a copay" — a plan that also reimburses the copay you paid in your health fund for surgery through the shaban.

These exemptions exist only if they're written in your policy — the commercial names look alike across companies, but the terms don't.

Where to find this in your policy

Two key places, both required under the Capital Market Authority's regulations:

• The disclosure form (גילוי נאות) table — a consolidated table at the start of the policy that lists, for each coverage, the insured amount, the copay and the caps.
• The insurance details page (דף פרטי הביטוח) — your personal document, with the plan you chose and the amounts that actually apply to you.

Look for the name of the coverage (for example "consultation with a specialist" or "medications not included in the health basket"), and next to it the copay and cap columns. If the numbers in the table are unclear or contradict what you were told — that's exactly the kind of question worth checking against the full policy wording before committing to a treatment.

How Ravit can help

The answers relevant to you are in the policy itself. Send Ravit your policy documents on WhatsApp, ask in plain language, and get an answer based on your policy with a reference to the relevant clause — and when there’s no certainty, Ravit says so honestly instead of guessing.

The information in this article is general only and does not constitute medical, insurance, legal, or pension advice, and is not a substitute for reading your policy terms or consulting a licensed professional. Coverage, amounts, and conditions vary between policies and change over time — always verify against your own specific policy and an authorized professional.