Yourhealth insurancedeductibleand your monthlypremiumsare probably your two largest healthcare expenses. Even though your deductible counts for the lion’s share of your healthcare spending budget,understanding what countstoward your health insurance deductible, and what doesn’t, isn’t always easy.
This article will help you understand what you need to know about health insurance deductibles and how your medical expenses are counted.
You need to read the fine print and be savvy to understand what, exactly, you’ll be expected to pay, and when, exactly, you’ll have to pay it.
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What Counts Toward the Deductible
Money gets credited toward your deductible depending on how your health plan’scost-sharingis structured. There are lots of ways cost-sharing can be structured, but most fall into two main design categories.
Plans Where You Pay First, Insurance Pays Later
Your health insurance might not pay a dime toward anything butpreventive careuntil you’ve met your deductible for the year. Before the deductible has been met, you pay for 100% of your medical bills.
After the deductible has been met, you pay onlycoinsurance(or copayments—copays—although that’s less common with this type of plan design) until you’ve met your plan’sout-of-pocket maximum. Your health insurance will pick up the rest of the tab.
In these plans, usually, any money you spend towardmedically-necessarycare counts toward your health insurance deductible as long as it’s a covered benefit of your health plan and you followed your health plan’s rules regardingreferrals,prior authorization, and using anin-network providerif required.
Although you’re paying 100% of your bills until you reach the deductible, that doesn’t mean you’re paying 100% of what the hospital and healthcare providersbillfor their services.
As long as you’re usingmedical providerswho are part of your insurance plan’snetwork, you’ll only have to pay the amount that your insurer has negotiated with the providers as part of their network agreement.
Although your healthcare provider might bill $200 for an office visit, if your insurer has a network agreement with your healthcare provider that calls for office visits to be $120, you’ll only have to pay $120 and it will count as paying 100% of the charges (the healthcare provider will have to write off the other $80 as part of their network agreement with your insurance plan).
Plans With the Deductible Waived for Some Services
In this plan type, your health insurance picks up part of the tab for some non-preventive services even before you’ve met your deductible. The services that areexcluded from the deductibleare usually services that require copayments. Whether or not the deductible has been met, you pay only the copayment for those services. Your health insurance pays the remainder of the service cost.
For services that requirecoinsurance rather than a copayment, you pay the full cost of the service until your deductible has been met (and again, “full cost” means the amount your insurer has negotiated with your medical provider, not the amount that the medical provider bills). After the deductible has been met, you pay only the coinsurance amount; your health plan pays the rest.
Examples of plans like this include what you might think of as a “typical” health insurance plan, with copays for office visits and prescriptions, but a deductible that applies to larger expenses such as hospitalizations or surgeries.
In these plans, the money you spend toward services for which the deductible has been waivedusually isn’t credited toward your deductible. For example, if you have a $35copaymentto see a specialist whether or not you’ve met the deductible, that $35 copayment probably won’t count toward your deductible.
However, this varies from health plan to health plan; read yourSummary of Benefits and Coveragecarefully, and call your health plan if you’re unsure.
Once you meet yourout-of-pocket maximumfor the year (including your deductible, coinsurance, and copayments), your insurer pays 100% of your remaining medically necessary, in-network expenses, assuming you continue to follow the health plans rules regarding prior authorizations and referrals. (Note that thisworks differently for inpatient care if you have Original Medicare).
The Deductible and Your Out-of-Pocket Maximum
Your health plan’s deductible can be any amount that ranges from as low as $0 to as high as the maximum allowed out-of-pocket limit.
Catastrophic health planshave deductibles that are exactly the same as the maximum allowable out-of-pocket cap.
What Doesn’t Count Toward the Deductible
There are several healthcare expenses that usually don’t count towards the deductible.
Not Covered Benefit
Your out-of-pocket expenses for healthcare services that aren’t a covered benefit of your health insurance won’t be credited toward your health insurance deductible.
For example, if your health insurance doesn’t coverbariatric surgeryor infertility treatments or vasectomies, the money you pay out of your own pocket for these services won’t count toward your health insurance deductible.
Out-of-Network Care
Money you paid to anout-of-networkprovider isn’t usually credited toward the deductible in a health plan that doesn’t cover out-of-network care. There are exceptions to this rule, such as emergency care or situations where there is no in-network provider capable of providing the needed service.
Federal rules require insurers to count the cost of out-of-network emergency care towards the patient’s regular in-networkcost-sharing requirements(deductible and out-of-pocket maximum) and prohibit the insurer from imposing higher cost-sharing for these services.
Health plans that cover out-of-network care in other circumstances, usuallyPPOsandPOSplans, may differ as to how they credit money you paid for out-of-network care. You may have two separate health insurance deductibles, one for in-network care and another larger one for out-of-network care.
In this case, money paid for out-of-network care gets credited toward the out-of-network deductible, but doesn’t count toward the in-network deductible unless it’s an emergency situation.
One caveat: If your out-of-network provider charges more than the allowedcustomary amountfor the service you received, your health plan will typically limit the amount it credits toward your out-of-network deductible to the customary amount.
This is done even though the out-of-network provider is allowed to bill you for the remainder of their charges (since they have no network agreement with your insurer, they’re not obligated to write off any portion of the bill).However, as noted above, this is no longer allowed for emergency care or situations in which a patient receives treatment from an out-of-network provider at an in-network hospital.
Copayments
Copayments generally do not count toward the deductible. If your health plan has a $20 copay for a primary care office visit, the $20 that you pay will most likely not count towards your deductible.
However, it will count towards your maximum out-of-pocket on almost all plans (some grandmothered andgrandfatheredplans can have different rules in terms of how their maximum out-of-pocket limits work).
Premiums
Monthlypremiums don’t count toward your deductible. In fact, premiums aren’t credited toward any type of cost-sharing. Premiums are the cost of buying the insurance.
They’re the price you pay the insurer for assuming part of the financial risk of your potential health care expenses. You have to pay the premium each month, regardless of whether you need health services that month or not, and regardless of whether you’d met your maximum out-of-pocket limit for the year. If you stop paying your premiums, your health insurance will lapse and you’ll no longer have coverage.
Summary
A health insurance deductible is the amount that you have to spend on certain services before your health plan will start to cover any of the cost of those services. The specific amount of the deductible will vary significantly from one plan to another. And the types of services that are subject to the deductible will also vary; some plans apply the deductible to nearly all services, while others will cover a wide range of services with copays even before the deductible (used for other services) is met.
A Word From Verywell
When you’re comparing health plans, the deductible is an important factor to keep in mind. But you’ll also want to pay close attention to what services—if any—the plan will cover with copays instead of requiring you to pay for them via the deductible.
Some health plans have very low deductibles but fairly high out-of-pocket maximums, so you’ll need tounderstand how much you might have to pay in coinsuranceafter you meet the deductible. Depending on the plan, you might find that you’re better off with a plan that has a higher deductible, if the total out-of-pocket costs are lower. This is particularly true if the monthly premiums are also lower, since you have to take the total cost—premiums plus out-of-pocket expenses—into consideration when you’re picking a health plan.
8 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.HealthCare.gov.Deductible.HealthCare.gov.Copayment.Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year.Miller, Stephen, CEBS. SHRM.Relief From Surprise Medical Billing Becomes Law. January 4, 2021.Centers for Medicare & Medicaid Services.Know your rights with insurance.healthinsurance.org.Out of network (out of plan).Schafer J, Gopalan A.Copayments not counting toward the deductible could have unintended consequences.Manag Care. 2017;26(12):34-35.HealthCare.gov.Premium.
8 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.HealthCare.gov.Deductible.HealthCare.gov.Copayment.Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year.Miller, Stephen, CEBS. SHRM.Relief From Surprise Medical Billing Becomes Law. January 4, 2021.Centers for Medicare & Medicaid Services.Know your rights with insurance.healthinsurance.org.Out of network (out of plan).Schafer J, Gopalan A.Copayments not counting toward the deductible could have unintended consequences.Manag Care. 2017;26(12):34-35.HealthCare.gov.Premium.
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
HealthCare.gov.Deductible.HealthCare.gov.Copayment.Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year.Miller, Stephen, CEBS. SHRM.Relief From Surprise Medical Billing Becomes Law. January 4, 2021.Centers for Medicare & Medicaid Services.Know your rights with insurance.healthinsurance.org.Out of network (out of plan).Schafer J, Gopalan A.Copayments not counting toward the deductible could have unintended consequences.Manag Care. 2017;26(12):34-35.HealthCare.gov.Premium.
HealthCare.gov.Deductible.
HealthCare.gov.Copayment.
Centers for Medicare and Medicaid Services.Premium Adjustment Percentage, Maximum Annual Limitation on Cost Sharing, Reduced Maximum Annual Limitation on Cost Sharing, and Required Contribution Percentage for the 2024 Benefit Year.
Miller, Stephen, CEBS. SHRM.Relief From Surprise Medical Billing Becomes Law. January 4, 2021.
Centers for Medicare & Medicaid Services.Know your rights with insurance.
healthinsurance.org.Out of network (out of plan).
Schafer J, Gopalan A.Copayments not counting toward the deductible could have unintended consequences.Manag Care. 2017;26(12):34-35.
HealthCare.gov.Premium.
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