Health Insurance Copay Explained

Last updated: 2026-06-25

What is a health insurance copay

Korea's health insurance (silson) — often called "silbi" (actual-cost) insurance — reimburses the medical costs you actually paid at a hospital. But it does not return the entire amount on your receipt. Policyholders are required to pay a portion of medical costs themselves, and this policyholder share is called the copay. The copay is a mechanism to reduce unnecessary overtreatment and to keep overall premiums from rising too steeply.

The copay is set as the larger of two amounts: first, the cost multiplied by the copay rate; second, the minimum deductible applied to outpatient visits. So when the bill is large, the copay-rate amount applies; when the bill is very small, the minimum deductible applies. The cost minus the copay is the reimbursement the insurer returns.

The difference between covered and non-covered care

To understand the copay, you first need to distinguish covered from non-covered care. Covered care is eligible for national health insurance — the "patient out-of-pocket" line on your bill. The national health insurance fund pays part, and only the remaining out-of-pocket amount is again eligible for silson reimbursement.

Non-covered care is not eligible for national health insurance and is paid fully by the patient. Common examples include manual therapy, non-covered injections (vitamin/nutrient shots, etc.), some MRIs and ultrasounds, and the differential for upgraded hospital rooms. From 4th-generation silson, covered and non-covered care use different copay rates, and some non-covered care (manual therapy, non-covered injections, MRI, etc.) is split into riders with separate count and amount limits and higher copay rates.

Copay rates by generation

Silson is divided into 1st–4th generations by launch period, and each generation has shifted toward higher policyholder copays. The table below shows general representative values; even within the same generation, products and riders can differ.

1st-generation silson has little or no copay and the most generous coverage, but it also saw the steepest premium increases. 4th-generation silson has higher copay rates but lower base premiums, and it introduced a "discount/surcharge" structure where next year's premium rises or falls with your non-covered usage. Whether to switch generations should be weighed carefully against your own pattern of medical use.

Outpatient minimum deductible

Outpatient visits always deduct a fixed minimum amount — the minimum deductible — even on small bills. It varies by facility size, and if the copay-rate amount is smaller than this minimum, the minimum deductible becomes your copay.

For example, if a clinic visit produced a covered out-of-pocket of ₩8,000, the 4th-generation copay rate of 20% gives ₩1,600, but the ₩10,000 minimum deductible is larger, so the copay becomes ₩10,000. In this case the bill is smaller than the minimum deductible, so there may effectively be no reimbursement. Inpatient care, by contrast, usually applies only the copay rate without a minimum deductible, within an annual out-of-pocket cap (e.g. ₩2,000,000).

Reimbursement calculation example

Suppose a 4th-generation silson policyholder visits a general hospital as an outpatient and pays a covered out-of-pocket of ₩50,000 and a non-covered cost (manual therapy) of ₩100,000. The covered copay is the larger of ₩50,000 × 20% = ₩10,000 and the ₩15,000 minimum, so ₩15,000. The non-covered copay is the larger of ₩100,000 × 30% = ₩30,000 and the ₩30,000 minimum, so ₩30,000. Total copay is ₩45,000, and reimbursement is (₩50,000 − ₩15,000) + (₩100,000 − ₩30,000) = ₩105,000.

If you want to try your own numbers, the Health Insurance Copay Calculator lets you enter visit type, generation, and covered/non-covered amounts to see your estimated reimbursement instantly.

What to check before you claim

• Check your generation — confirm your silson generation and copay rate first, on your policy certificate or insurer's app.
• Rider limits — manual therapy, non-covered injections, MRI, etc. have count and amount limits; over the limit, they are not reimbursed.
• Annual limits — inpatient and outpatient care have annual reimbursement caps and visit-count limits.
• Duplicate enrollment — silson reimburses proportionally, so holding several plans does not pay you above your actual loss.
• Prepare documents — having the itemized statement, receipt, and diagnosis ready in advance speeds up the review.

Health insurance is high-value and is usually the first coverage to secure. If you want to understand coverage priorities overall, run a check that fits your age and family in the Insurance Buying Guide (Coverage Analysis). For retirement, check pension accumulation and payout with the Pension Insurance Payout Calculator.

Last updated: 2026-06-25