Health Insurance Deductible

A deductible is an amount you pay before the Insurance Company starts paying. Health insurance plans will have different deductibles. Low deductible examples might be a “Gold” plan, with example deductibles of $500, $1,000, $2000, etc. An example of a “Silver” plan might have a higher deductible such as $4,000, $5,000, etc. A higher deductible would be seen in a “Bronze” plan at a deductible of about $8,700. But still, what is a deductible?

Think of it like getting to 1st base in a game of baseball. You start on home plate, and when you get your first medical bill, you’d start running towards 1st base. Beginning to pay towards meeting your deductible. You’ll be expected to pay the whole medical bill out of your own pocket until you’ve paid your deductible, or in other words, reaching 1st base using our analogy.

The very good news is, no matter what the deductible is, you will most likely pay what the insurance company has “negotiated” with the doctor or hospital, even before you’ve paid off your full deductible. As an example, if you have a $1,000 doctor bill because you visited a dermatologist for burning off a wart, the insurance company may have a negotiated a price of about $300 with that doctor, instead of having to pay the full $1000. That $300 you pay will apply to your deductible. So, if you have a $4000 deductible, now you’d have $3700 left of your deductible. Make sense?

Once you’ve paid all your deductible, you are standing on 1st base, using our baseball analogy. Until you’ve paid all $4000 using our deductible example, you’ve not reached 1st base yet. But once you’ve come out of pocket the full $4000, now you’ll begin to move towards 2nd base – “Co-Insurance”. During this time, co-insurance is where you and the insurance company split the medical bills. Some examples, 70/30, 80/20 or 60/40. Make sure to look at your health plan to see what your deductible and co-insurance are.

So, using our $4000 deductible scenario, and dermatology bill, if you have already paid the $4000 earlier in the year, and you are standing on 1st base and now heading for 2nd base, now you’ll pay a split with the insurance company. If your co-insurance was 30%, you’ll pay using our example of $300 (negotiated price of the $1000), you’d pay 30% of $300 which is $90. So, heading to 2nd base, called “co-insurance”, you’ll pay a split of an already discounted price. Usually, the insurance company will pay the larger amount (70%) and you’d pay the lesser amount.

Your next step is 3rd base or your “Out of Pocket Maximum”. This is the maximum YOU have to pay in a year, not the insurance company. Once you’ve paid the “out of pocket maximum”, there will be no additional charges, including cost of medications. The insurance company will pick you up on 3rd base and carry you to home plate. You are all done paying for the year. Please check the details of your plan for deductible, co-insurance and out of pocket maximum.