What is a deductible?

What is a deductible?

Read this if you have insurance and are wondering why you still have a bill.

So you have health insurance but you get a bill saying you have to pay your deductible.  What is a deductible? Navigating the world of health insurance can be a daunting task.  In this comprehensive guide, we’ll break down everything you need to know about deductibles – from what they are and how they work to how they affect your premiums and claims.

What is a deductible?

A deductible is the amount of money you have to pay out of pocket before your insurance coverage kicks in. It is part of your insurance contract. It’s essentially your share of the cost of any covered expenses. For example, if you have a health insurance policy with a $1,000 deductible and you need to undergo a medical procedure that costs $5,000, you would be responsible for paying the first $1,000, while your insurance company would cover the remaining $4,000. Deductibles can vary greatly depending on the type of insurance policy you have and the coverage you’ve selected. They can range from as low as $100 to as high as several thousand dollars.

Deductibles serve two main purposes. Firstly, they help prevent insurance fraud by discouraging policyholders from making small or unnecessary claims. Secondly, they help keep insurance premiums affordable by shifting some of the financial burden onto the policyholder. By requiring individuals to pay a portion of the costs, insurance companies are able to offer coverage at a lower overall cost.

In most cases, deductibles apply on an annual basis. This means that once you have met your deductible for the year, you won’t have to pay it again until your policy renews. However, it’s important to note that some policies may have different requirements for specific services or treatments.

“But I’m covered by insurance!” How deductibles work?

It’s important to note that deductibles only apply to covered expenses. If your health care service was not covered by your insurance policy, you would be responsible for paying the full amount out-of-pocket.

Once you’ve met your deductible, your insurance coverage will kick in and cover the remaining expenses up to the limits of your policy. For example, if your health insurance policy has a $1,000 deductible and a $10,000 limit, once you’ve paid the first $1,000, your insurance company will cover the remaining $9,000 of covered expenses.

“Do I have to pay my deductible?”

Yes, if the deductible is for a legitimate service received that is covered under the insurance plan.  Like when a doctor submits a claim for a service not provided, not paying a deductible is considered health insurance fraud on the part of the patient.

Health insurance deductibles

Health insurance policies typically have both individual and family deductibles. An individual deductible applies to each insured person, while a family deductible applies to all members covered under the policy. For example, if you have a family health insurance policy with a $2,000 individual deductible and a $4,000 family deductible, each family member would need to meet the individual deductible before the family deductible is considered.

In-network vs out-of-network and deductibles

Health insurance deductibles can also vary depending on whether you choose an in-network or out-of-network provider. In-network providers have negotiated rates with your insurance company, which means the cost of services is typically lower. Out-of-network providers, on the other hand, do not have negotiated rates and may result in higher out-of-pocket costs. Some health insurance plans have out-of-network benefits that will pay a percentage of fees from services from out-of-network providers.  Check with your health insurance company.

Deductible vs surprise bill

Although some people are surprised to get a bill for a deductible or a copay, this is not a what is called a surprise bill. As surprise bill is an unexpected bill from an out-of-network provider or facility.  A deductible, copay, or coinsurance bill is part the contract for an in-network provider.

READ: What is a copay?

Pros and cons of high and low deductibles

When choosing a deductible, it’s important to consider the pros and cons of both high and low deductibles. Let’s explore the advantages and disadvantages of each.


High deductibles

High deductibles are typically associated with lower premiums. By opting for a higher deductible, you can reduce your monthly insurance costs. This can be especially beneficial if you’re generally healthy and don’t anticipate making frequent claims.

However, high deductibles mean you’ll have to pay more out-of-pocket in the event of a claim. This can be a financial burden, especially if you have a sudden need for medical care. High deductibles may also discourage individuals from seeking necessary medical treatment, which can result in more serious issues down the line.

Low deductibles

Low deductibles, on the other hand, provide more immediate financial relief in the event of a claim. With a lower deductible, you’ll pay less out of pocket before your insurance coverage kicks in. This can be beneficial if you anticipate needing frequent medical care or if your vehicle is at a higher risk of accidents or theft.

However, low deductibles usually come with higher premiums. You’ll be paying more on a monthly basis to have the lower deductible option. If you’re generally healthy or have a safe driving record, you may end up paying more in premiums than you would in out-of-pocket costs with a higher deductible.

Factors to consider when choosing health insurance

Choosing the right insurance policy requires careful consideration of your specific needs and financial situation. Here are some factors to keep in mind when making your decision:

Budget and financial stability

Consider your budget and financial stability when choosing a deductible. Can you comfortably afford to pay a higher deductible out of pocket in the event of a claim? If not, it may be wise to opt for a lower deductible that provides more immediate financial relief.

Risk tolerance

Evaluate your risk tolerance when selecting a deductible. Are you willing to take on more financial risk in exchange for lower premiums? Or do you prefer the peace of mind that comes with a lower deductible? Assess your comfort level and choose accordingly.

Anticipated claims

Consider your history of claims and anticipated future needs. Have you made frequent claims in the past? Do you anticipate needing medical care. These factors can help guide your decision on whether to opt for a higher or lower deductible.

Premium savings

Compare the savings in premiums between different deductible options. Calculate how much you’ll save on a monthly or annual basis by choosing a higher deductible. Then, weigh that against the potential out-of-pocket costs in the event of a claim.

Understanding health insurance deductible limits

Deductibles are often subject to certain limits, which can vary depending on your insurance policy. These limits determine the maximum amount you’ll have to pay out-of-pocket before your insurance coverage kicks in. Let’s take a closer look at deductible limits for different types of insurance.

Health insurance policies typically have both individual and family deductible limits. The individual limit is the maximum amount an individual policyholder has to pay out of pocket in a given year, while the family limit is the maximum amount for all members covered under a family policy.

Once you’ve reached the deductible limit, your insurance coverage will kick in and cover all or a percentage of the remaining expenses, depending on your policy. It’s important to note that some services may be exempt from the deductible, such as preventive care or prescription drugs, which may be covered without requiring you to meet your deductible. Certain services or procedures may have a deductible whereas others do not.

How to calculate deductible expenses

After your doctor, other health care provider or hospital submits a bill, your insurance company will process the claim and generate what is called an explanation of benefits, or EOB  The EOB is usually sent to the patient or is available on the insurance website. The EOB includes information about services, fees, and patient responsibility — which would include whether there are any covered fees that will have to be covered by the deductible.  It’s a good idea to consult with your insurance provider or a financial advisor if you are unsure of the guidelines set forth in your policy.


Managing deductible expenses effectively can help reduce your financial burden and make insurance more affordable. Here are some strategies to consider:

Build an emergency fund

Having an emergency fund can provide a safety net in the event of unexpected expenses. This may be your Health Spending Account (HSA) plan. By setting aside money specifically for deductibles, you’ll be better prepared to handle out-of-pocket costs without straining your budget.

Choose the right coverage

Carefully evaluate your insurance needs and choose the appropriate coverage for your specific situation. If you’re generally healthy and don’t anticipate needing frequent medical care, a higher deductible health insurance plan may be a good option. On the other hand, if you have ongoing health conditions or require regular treatments, a lower deductible plan may be more suitable.

Utilize preventive care

Take advantage of preventive care services offered by your health insurance. These services are often exempt from the deductible and can help you maintain good health and catch potential issues early on, avoiding more costly treatments down the line.

Shop around for the best rates

Don’t settle for the first insurance provider you come across. Take the time to shop around and compare rates from different companies. This can help you find the best coverage at the most affordable price.

Common misconceptions about deductibles

There are several common misconceptions that can lead to confusion. Let’s debunk some of these myths:

Myth: I have to pay my deductible for every claim.

Fact: Deductibles typically apply on an annual basis. Once you’ve met your obligation for the year, you won’t have to pay it again until your policy renews.

Myth: I should always choose the lowest deductible available.

Fact: While a low deductible may provide more immediate financial relief, it often comes with higher premiums. Consider your specific needs and financial situation to determine which deductible option is best for you.

Myth: My deductible is the same as my coverage limit.

Fact: Deductibles and coverage limits are separate. Deductibles determine the amount you’ll have to pay out of pocket before your insurance coverage kicks in, while coverage limits refer to the maximum amount your insurance company will pay for a claim.


Understanding deductibles is essential for navigating the world of health insurance. By knowing what they are, how they work, and the different types of deductibles that exist, you can make informed decisions when choosing the right coverage for your needs.

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