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Medical insurance, often known as health insurance, is a type of insurance that covers all or part  of a person’s risk of incurring medical bills. Risk exists among many people, just as it does with  other types of insurance. An insurer can design a routine finance structure, such as a monthly  premium or payroll tax, to provide the money to pay for the health care benefits stipulated in the  insurance agreement by calculating the overall risk of health risk and health system expenses  over the risk pool. A central institution, such as a government agency, a commercial enterprise,  or a not-for-profit organization, is in charge of administering the benefit.

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Health Insurance Deductible

A health insurance deductible is a predetermined amount or limited limit that you must pay  before your insurer will cover your medical expenses. If your deductible is $1,000, for example,  you must first pay $1,000 out of cash before your insurance would cover any of the costs  associated with a medical visit. It could take several months or perhaps just one visit to reach  your deductible. 

Your deductible payment will be sent directly to the doctor, clinic, or hospital. If you have a  $700 charge at the emergency department and a $300 charge at the dermatologist, you will pay  the hospital $700 and the dermatologist $300 immediately. Your deductible is not paid to your  insurance carrier. You’ve reached your deductible now that you’ve paid $1000. Your insurance  provider will then begin paying for your medical bills that are covered by your policy. 

At the start of your policy period, your deductible is reset to $0 automatically. The majority of  policy periods are one year long. You’ll be responsible for paying your deductible until it’s met  when the next coverage period begins. Even if the deductible has been met, you may still be  responsible for a copayment or coinsurance, but the insurance company is covering at least a  portion of the cost. 

  • Many plans cover some services, such as a checkup or disease management programs,  even if your deductible hasn’t been met. Examine the specifics of your plan.
  • Even before you reach your deductible, all Marketplace health plans cover the full cost of  certain preventative services. 
  • Certain services, including as prescription medicines, have separate deductibles in some  plans. 
  • Individual deductibles, which apply to each person, and family deductibles, which apply  to everyone in the family, are common in family plans. 

Plans with lower monthly rates typically have higher deductibles. Deductibles are frequently  lower in plans with greater monthly premiums. 

How does health insurance deductible work? 

A deductible is a predetermined amount you must pay out of pocket before your insurance plan  begins to pay for covered expenses. A deductible is not included in every health plan, and the amount varies per plan. Every year, it all starts afresh, and you’ll have to meet your deductible  before your plan benefits kick in. Keep in mind that only the money you spend on covered  medical expenses counts toward your plan. The amount of your annual deductible varies greatly  depending on your health insurance plan. Annual deductibles are lower in plans with higher  metal levels (such as “gold” or “platinum”), but monthly premiums are greater. Cheaper-metal level plans (such as “bronze”) offer lower monthly premiums but greater yearly deductibles.  Individual plan deductibles fell on average in 2019.

infographic average annual deductibles for individual and family 2018 and 2019

Copayments in health insurance

After you’ve paid your deductible, you pay a set amount ($20, for example) for a covered health care service. Let’s imagine the maximum authorized fee for a doctor’s office visit under your  health insurance plan is $100. A $20 copayment is required for a doctor’s appointment. 

  • If your deductible has been met, you will be charged $20 at the time of your appointment. If your deductible has not been met, you must pay the full fee for the visit, which is $100. 

Within the same plan, copayments (often known as “copays”) can vary for different services such  as medicines, lab tests, and specialist appointments. Copayments are typically greater in plans  with lower monthly rates. Copayments are frequently cheaper in plans with larger monthly  premiums. 

Deductible vs. Copayments

Once you’ve met your deductible, your health insurance will start paying for your medical bills.  You may, however, be liable for a charge each time you use the insurance. A copayment is the  amount you are responsible for paying toward a medical insurance claim. In most circumstances,  the copayment will be requested at the time of your visit.

Copayments are normally set at a low level. You may, for example, be required to pay a $25  copay each time you visit your general practitioner. The amount varies depending on the  insurance plan. The copayment isn’t always a fixed sum. Instead, you can repay a certain  percentage based on how much your insurance will pay for the visit. 

For example, your copayment could be 10% of the charges for your appointment. A single visit  could cost up to $90. Another option is $400. As a result, your copayment may vary from session  to appointment. If you go to a doctor, clinic, or hospital that isn’t part of your insurance’s  approved network, you may be charged a different copayment than if you go to one that is.

shannon kennedy, president SASid

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About the author

Shannon Kennedy, Licensed Insurance Agent

With a passion for insurance since he was in high school, Shannon Kennedy received his life & health license at the age of 18.  SASid is a nationally licensed and recognized health insurance agency sincerely helping people access and understand insurance. We don’t want you to be intimidated. Contact our Support Center for answers to your questions.

Need help with your insurance options?
Call Shannon at 855-826-0030