A Guide to Deductibles

Deductibles can be confusing but they have a big impact on how your insurance covers your healthcare. At Better, many of the claims we process are often applied to the deductible. This is how deductibles work.

What Is a Deductible?

Most health insurance policies carry deductibles. The deductible is the amount you must pay out-of-pocket before your insurance starts to cover your care. Deductibles can be as low as $0 or as high as $28,000. In 2016, the Kaiser Foundation found the average deductible for employer plans to be $1,478. High-deductible plans (HDHP), as their name suggests, are plans that offer lower premiums in exchange for deductibles that average $5,762.

In-Network Deductible

This is the amount you must pay out-of-pocket before your insurance starts to pay for healthcare. This applies only when you visit healthcare providers who are in your insurance network. After this deductible has been met you are only on the hook for your co-payment. It’s very common to see a $20 co-payment to see a primary care provider, $40-$60 to see a specialist and $100-$300 to go to the ER. However, before that deductible is met you are responsible for paying the doctor the contracted rate in full for the care you receive.

Out-of-Network Deductible

This is often separate from your in-network deductible. It is the amount you must pay for out-of-network treatment before your insurance will begin to pay you back for any portion of the costs. When you see healthcare providers that do not take your insurance, they are able to charge you any amount they choose. Unlike in-network providers, they do not have a contract in place with your insurance that controls what they can bill you. However, your insurance will still use their internal prices, called allowed amounts, when calculating how much of each visit applies to your deductible. This can often take people by surprise when they see how a claim has processed.

Combined Deductibles

Some policies offer combined deductibles. This means that your in-network and out-of-network deductibles are treated as one amount. Anytime you see a doctor, whether inside our outside your plans network the amount covered will be applied to your single deductible.

Family Deductibles

For policies with multiple family members on them, there is one number per individual and one number for the family. These are also called embedded deductibles. Any amount applied towards any family member’s individual deductible is also applied to the family deductible. Once that family deductible has been met all individual deductibles are considered met as well. Then your insurance will begin to cover the cost of care for your entire family.

Deductible Carve-Outs

Your policy can separate deductibles for different types of care that can really catch you by surprise. These can be for pharmacy benefits, chiropractic care, or in-patient hospitalization. Before accessing a new type of care it is a good idea to check to see if there is a separate deductible that will affect your coverage.

High Deductible Policies (HPHD)

Many people have seen their deductibles rise dramatically over the past few years. If you are involved in a medical emergency, you could be in for a big financial shock.

“Although consumers with HDHPs do tend to reduce costs, they do so by skipping out on care, according to the Urban Institute. (Nerd Wallet)”

Healthcare Without the Deductible

Under the Affordable Care Act, health plans must cover certain essential medical services, even if your deductible is not met and as long as you use an in-network doctor. These medical services include an annual checkup, vaccinations, and screening tests for a wide range of common medical conditions. Here are some of the most common:

· Blood pressure and cholesterol screening

· Cancer screening

· Vaccinations (including flu shots)

· Annual mammogram screening

· Colonoscopy (for patients over 50)

These are free services, paid for by your premium. You do not need to have met your deductible to have access to any of this medical care. If you are prevented from accessing these services, you should contact your insurance company or government consumer services.

If you have questions about your deductible or how your plan works, get in touch! We are always happy to help. Contact us at support@getbetter.co