Health Insurance Deductible Definition – InvestopediaMay 18, 2022
Thomas J Catalano is a CFP and Registered Investment Adviser with the state of South Carolina, where he launched his own financial advisory firm in 2018. Thomas' experience gives him expertise in a variety of areas including investments, retirement, insurance, and financial planning.
A health insurance deductible is a set amount of money that an insured person must pay out of pocket every year for eligible healthcare services before the insurance plan begins to pay any benefits.
The amount of the deductible varies depending on the health insurance plan you choose. As a general rule, the higher the monthly premium you pay, the lower the deductible. Your monthly premium is the amount you pay to a health insurance company to provide you with coverage.
Even after you pay off your deductible for the year, you may still have to pick up some of your healthcare costs. Most insurance plans have copayments, which require the insured to pay a set dollar amount as their share of the cost of some services. Most also have coinsurance payments, which make the insured responsible for a set percentage of the total cost of some services.
When you buy health insurance, you pay a set monthly premium for one year of coverage. At the end of the year, you may continue your coverage, although the insurer may revise the premium amount at that time.
The annual deductible is separate from the monthly premium and must be used up before any services are covered by the insurance company. For example, if a plan has a $1,000 annual deductible and a patient needs a procedure that costs $3,000, the patient would need to pay the $1,000 deductible, while the insurance company would pay the remaining $2,000, assuming the procedure was covered under that health plan.
After the deductible is paid, your medical costs are covered, minus the monthly premiums and any copayment owed for those expenses. However, when a new year begins, the deductible clock is reset.
Your plan might have several different deductibles for various services. If you have individual coverage, you may pay one deductible for most of your healthcare expenses and another toward the cost of prescription drugs. If you have family coverage, you may pay individual deductibles for each person covered and a family deductible for the policy.
Many insurance plans pay for certain preventive care services without requiring you to pay any deductible or copay. For example, routine mammograms for women age 40 and over are covered in full with no deductible or copay. This is a federal requirement for new plans.
Insurance companies charge deductibles in part as a cost-saving measure. The logic is that anyone who is insured and has to pay out of pocket will think twice before using an emergency room or medical services if they don't really need them.
Americans who have health insurance must pay between 10% and 40% of their own annual healthcare costs, depending on whether they go for a higher-premium or a lower-premium plan.
Once you pay off the deductible, your health insurance plan will pick up your medical costs, with a couple of exceptions.
Copayments are one exception. Your copay is a set dollar amount that you may pay for a doctor’s visit, a prescription, or a visit to an urgent care facility. These amounts may not count toward your deductible for the year, and once you pay off your deductible, you’ll still have to pay them.
Copayments are not the same as coinsurance, which is the percentage of a bill for a medical service that you will be responsible for paying after you’ve met your deductible.
Here are two examples:
The amount you pay for your deductible, copayments, and coinsurance all count toward your annual out-of-pocket maximum, which is the total you must pay before your insurance plan begins paying 100%.
The maximum out-of-pocket annual cost, as of 2021, is $8,550 for an individual plan and $17,100 for a family plan. For 2022, those limits increase to $8,700 and $17,400, respectively.
Medicare is available for people age 65 or older. Medicare Part A pays for inpatient hospital stays and nursing care. The annual deductible for Part A is $1,484 for 2021 and $1,556 for 2022. Many people don't pay a monthly premium for Part A, and there are no coinsurance costs for hospital stays of 60 days or less.
Medicare Part B covers doctor's visits, tests, flu shots, physical therapy, and chemotherapy. The monthly premium for many Part B participants is $148.50 for 2021 and $170.10 for 2022. The Part B deductible is $203 for 2021 and $233 for 2022.
In 2020, the most recent year for these figures, the average cost of a high-deductible health plan for an individual was $4,971 a year while the average cost for a low-deductible plan was $7,816.
This is how much the average American paid for health care premiums and deductibles as of the end of 2020:
These figures do not include copayments or coinsurance.
If you're shopping for a health insurance plan, each plan you're offered will include a full list of that plan's copayments and coinsurance. Most insurers will offer high-, medium-, and low-deductible plans, each with its own details.
The minimum deductible for family coverage to qualify as a high deductible health plan in 2021 and 2022. The minimum deductible for single coverage is $1,400.
As you can see, there's a substantial difference in the monthly premiums of high deductible versus low deductible healthcare plans. However, the real out-of-pocket costs of any plan include the premium, the deductible, and any coinsurance.
The amount anyone pays in out-of-pocket expenses depends on the individual's health profile. A young and healthy person who rarely goes to a doctor might gamble on a high deductible plan with high coinsurance costs. Someone who requires regular treatment for a chronic condition might go for a higher-level plan to minimize deductible and coinsurance costs.
If you're in good health and have no health issues, it's possible that you may not even spend enough to meet your plan's deductible for the year. You'd have to consider whether it would make more sense to opt for a plan with a lower monthly premium and a higher deductible.
If you're married, you may also need to compare the deductible for your spouse's health insurance coverage and how much it would be if you opted to add yourself to the spouse's insurance. Depending on how the plan is structured, it may be more affordable to go from single to family coverage.
If you're getting health insurance through the federal marketplace or any of the state marketplaces, you can compare the coverage of four distinct tiers to determine which one is best for you.
The plans offered directly by insurers are similar to those that are available in the health insurance marketplaces that the federal government and many states have made available under the Affordable Care Act. The marketplaces offer four tiers of insurance plans:
Notably, there's also a catastrophic plan that has a very high deductible—$8,150 in 2020—for people under age 30, or those who have a hardship or affordability exemption.
When comparing health insurance plans, the important factors are the amount of the deductible, the coverage provided in the plan, and how often you need medical care.
Pricing for all of the plans depends on your age, whether you smoke, and where you live. The state in which you live determines the companies that offer to insure you and the price you'll pay.
At the Bronze level, you would typically have the lowest monthly premium, but you'd pay the highest deductible. At the other end of the spectrum, a Platinum plan would offer the most coverage for healthcare plus the lowest deductible.
The Platinum plan could be a good choice if you have high costs for routine care, specialists, or prescription drugs. The trade-off is that the plan will have an expensive monthly premium.
Those who get their insurance through the federal marketplace are automatically evaluated for their qualification for any cost-sharing discounts based on income. You must enroll at the Silver level or higher, but if a cost-sharing reduction is available, this will reduce the amount you pay for coverage.
If you're choosing a healthcare plan and want to compare costs, you need to do some math: monthly premium plus copayments plus coinsurance equals your total annual out-of-pocket costs of that plan.
Of course, you probably can't estimate how many doctor's visits you will need in the coming year, and you don't know whether you will face a severe illness or injury.
So go with what you know. If you're young and generally healthy, you might take a high deductible plan. Be prepared to foot much of the bill if you become ill.
If you have a recurring health problem requiring specialists' routine treatment, consider the low deductible plan. You'll pay a higher premium but should get a break on the deductible, copayments, and coinsurance costs.
The Medicare Part A deductible is $1,484 for 2021 and will be $1,556 in 2022. It pays inpatient hospital stays, nursing care, and hospice care. Most people do not pay a monthly premium for Part A coverage. There are no coinsurance costs for hospital stays of 60 days or less.
The Medicare Part B deductible is $203 for 2021 and $233 for 2022. Most Medicare participants also pay a monthly premium for Part B, which is $148.50 for 2021 and $170.10 for 2022. Medicare Part B covers doctor's visits, tests, flu shots, physical therapy, and even chemotherapy. It's essentially all healthcare costs that don't involve hospitalization or prescription drugs.
Yes, there usually is. Medicare Part D is coverage for prescription drug costs. It's an optional extra for Medicare and is available through private insurers, although you can sign up for it through the Medicare.gov website.
The insurers who offer Part D coverage can be located via the Medicare.org website's Medicare Plan Finder.
Yes. The Medicare Advantage Plan is one of two alternatives for Medicare recipients who want to supplement the coverage they receive. Both are available through private insurers.
Medicare Advantage Plan
A Medicare Advantage Plan replaces your Medicare card with a private insurer's Medicare Advantage Plan card. That insurer manages your Part A, Part B, and (optional) Part D services and costs.
Its coverage has its own premiums (an average of $19 monthly in 2022), copayments, and coinsurance costs.
It will offer additional coverage and additional services at an additional cost. The costs vary widely, as do the options for coverage.
Medicare Supplement Insurance, known as Medigap, covers some of the deductibles, coinsurance, and copayments due for Medicare services.
For example, you can choose a Medigap plan that has a low monthly premium but requires you to pick up the deductible every year. But if you're hospitalized for more than 60 days, it will pick up your share of the costs.
HealthCare.gov. "Subsidized Coverage." Accessed Nov. 29, 2021.
Health Resources & Services Administration. "Women's Preventive Guidelines." Accessed Nov. 29, 2021.
HealthCare.gov. "The 'Metal' Categories: Bronze, Silver, Gold & Platinum." Accessed Nov. 29, 2021.
HealthCare.gov. "Out-of-Pocket Maximum/Limit." Accessed Nov. 29, 2021.
Medicare.gov. "Medicare Costs At a Glance." Accessed Nov. 29, 2021.
U.S. Department of Health and Human Services. "What Does Part B of Medicare (Medical Insurance) Cover?" Accessed Nov. 29, 2021.
Centers for Medicare & Medicaid Services. "CMS Announces 2022 Medicare Part B Premiums." Accessed Nov. 29, 2021.
ValuePenguin. "51% of U.S. Workforce Enrolled in High-Deductible Health Plans, Which May Leave Some Underinsured." Accessed Nov. 29, 2021.
eHealth. "How Much Does Individual Health Insurance Cost?" Accessed Nov. 29, 2021.
eHealth. "Average Cost of Employer-Sponsored Health Insurance." Accessed Nov. 29, 2021.
HealthCare.gov. "High Deductible Health Plan (HDHP)." Accessed Nov. 29, 2021.
HealthCare.gov. "Catastrophic Health Plans." Accessed Nov. 29, 2021.
Centers for Medicare & Medicaid Services. "Fact Sheet, 2022 Medicare Parts A & B Premiums and Deductibles 2022 Medicare Part D Income-Related Monthly Adjustment Amounts.” Accessed Nov. 29, 2021.
Medicare.gov. "How to Get Prescription Drug Coverage." Accessed Nov. 29, 2021.
Medicare.gov. "Drug Coverage (Part D)." Accessed Nov. 29, 2021.
Centers for Medicare & Medicaid Services. "CMS Releases 2022 Premiums and Cost-Sharing Information for Medicare Advantage and Prescription Drug Plans." Accessed Nov. 29, 2021.
Medicare.gov. "Medicare Advantage Plans." Accessed Nov. 29, 2021.
Medicare.gov. "What's Medicare Supplement Insurance?" Accessed Nov. 29, 2021.
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