A health insurance deductible is a way to pay for health coverage when you need medical services.
Health insurance deductibles affect not only how much you pay when you get medical care, but they also influence your health insurance premiums. health plans typically charge lower premiums for plans with higher deductibles and higher premiums for plans with lower deductibles.
what is a deductible in health insurance?
A health insurance deductible is the amount you pay out of pocket before your insurance company pays a portion of your health care expenses.
“If your insurance plan includes a deductible, you are 100% responsible for all of your medical costs until you meet your deductible,” says Janice Johnston, M.D., chief medical officer and co-founder of redirect health.
Deductibles are generally set annually, meaning they reset at the beginning of each year. if you have family coverage, you may have family deductibles or individual and family deductibles, depending on the health plan.
Once you meet your deductible, a health plan’s coinsurance usually kicks in and the health insurance company helps pay a portion of your health care costs.
how health insurance deductibles work
Health plans generally count the money you spend on covered health care services, like in-network doctor visits and tests, toward your deductible. out-of-network care generally doesn’t count toward your deductible.
let’s say you go to the doctor and need tests. the total visit costs you $500. in that case, you’d pay the bill and $500 would go toward your deductible. if your plan’s deductible is $1,000, you’re halfway there.
Once you meet your deductible, that’s when you need to know about coinsurance and out-of-pocket maximums.
how do you reach an out-of-pocket maximum?
Health insurance plans have out-of-pocket maximums, which is the most you’ll pay in a year, including deductibles and coinsurance. Health insurance premiums are not included in your deductible or out-of-pocket maximum.
once you meet your plan’s deductible, you and your health insurance company will split the costs of care. this is called coinsurance and is usually a percentage, such as 20%/80%. In this example, the member pays 20% of health care costs after meeting the deductible and the health plan pays the other 80%.
You pay your share of coinsurance until you reach the plan’s out-of-pocket maximum. Once you reach your out-of-pocket maximum, the health insurance company pays 100% of your health care costs.
let’s see an example.
- Your health plan has a $1,000 deductible, 20%/80% coinsurance, and a $5,000 out-of-pocket maximum.
- needs multiple health care services, including tests and an MRI, in the first few months of the year. you pay the first $1,000 and meet your deductible.
- For the next few months, you will need outpatient care and spend a day in the hospital. you and your health plan use coinsurance to split those costs 20%/80% and you end up reaching your $5,000 out-of-pocket maximum.
- For the rest of the year, your health plan pays 100% of the costs of health care when you need it.
- blood pressure screenings
- hiv screenings
- obesity screening and counseling
- tobacco use assessments
- lung cancer screenings
- fall prevention
health insurance cost definitions
different types of health insurance deductibles
Depending on your health insurance plan, you may have an individual deductible, a family deductible, or a combination of the two.
If you have individual coverage, an individual deductible calculates your health care costs. once you meet that deductible, you go to the coinsurance portion and split your health care costs with your health plan until you reach the out-of-pocket maximum.
A family plan may have individual deductibles as well as family deductibles.
Family coverage has two types of deductibles:
An aggregate deductible means your family has a total deductible for the entire family. there are no individual deductibles for each person in those plans.
A built-in deductible plan has a family deductible and individual deductibles for each family member. When a family member meets their individual deductible, the health plan splits the costs through coinsurance for that person’s care. the rest of the family continues to pay up to the individual deductible for their care.
an embedded deductible also has a family deductible. If the family is combined to meet the overall family deductible, the health plan pays coinsurance for the entire family until the out-of-pocket maximum is met.
what is a high deductible health plan?
A high-deductible health plan (HDHP) is one with a deductible of at least $1,400 for individual coverage or $2,800 for family coverage, according to the IRS. A high-deductible health plan has annual in-network out-of-pocket costs of no more than $7,050 for individual coverage or $14,100 for a family.
These plans have higher out-of-pocket costs and generally lower premiums, so you pay less for coverage but more when you need health care. A high-deductible health plan is often paired with a health savings account (HSA), which allows you to save money tax-free for future health care needs.
hdhps can be a great option for healthy people who don’t need a lot of medical care, but can be expensive if you need regular services or have a family plan with multiple medical needs.
Is high or low deductible health insurance better?
Deciding whether a high or low deductible plan is better often depends on how often you plan to need medical care during the year.
who benefits from high deductible health insurance?
who benefits from low deductible health insurance?
how to calculate, manage and monitor health insurance deductibles
One way to stay on top of your health insurance deductible is to closely monitor your spending against the plan’s annual deductible, which resets each year, warns dr. darshak sanghavi, global medical director of babylon health, a healthcare company that specializes in 24/7 telehealth consultations.
If you anticipate needing an expensive procedure that will force you to meet your deductible, you may want to schedule it earlier in the year.
Also, take advantage of the tools on your insurance company’s website and compare costs between doctors, Sanghavi recommends. “Some insurance sites also offer cost estimation tools that give an individual the price he will pay among various providers for a CT scan or surgery,” she says.
Also, make sure you know what services are free under your insurance plan. “For example, preventive care and screenings are free and can help catch problems early, lowering costs down the road,” Sanghavi says. As long as the following services are provided by a provider in your plan’s network, you often will not have to pay for them. this could include:
How should I choose a health insurance deductible?
what is a good deductible for health insurance depends on your health and financial situation.
Choosing a health insurance deductible requires you to think about your current health care needs and what you expect in the coming year. do you plan to have a child? do you expect to need surgery?
He also wants to see your finances. Can you afford unexpected health care costs if you need care, or would you prefer to pay higher, predictable premiums up front for coverage?
If you’re in good health or have enough money saved to pay the annual deductible, a high-deductible plan may be more affordable due to lower health insurance premium costs. But if you have medical conditions that need frequent care, a plan with a lower deductible and higher premiums may make more sense.
Whether you get health insurance through your employer or the low-priced health care law marketplace, you usually have multiple options to choose from. use health insurance open enrollment to explore your options.
Once you determine your expected health care needs and decide if you prefer to pay more up front when you need care, you can choose the health insurance deductible that’s right for you.