The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.
After you pay your deductible, you usually pay only a copayment or coinsurance for covered services. Your insurance company pays the rest.
- Many plans pay for certain services, like a checkup or disease management programs, before you’ve met your deductible. Check your plan details.
- All Marketplace health plans pay the full cost of certain preventive benefits even before you meet your deductible.
- Some plans have separate deductibles for certain services, like prescription drugs.
- Family plans often have both an individual deductible, which applies to each person, and a family deductible, which applies to all family members.
Generally, plans with lower monthly premiums have higher deductibles. Plans with higher monthly premiums usually have lower deductibles.
A fixed amount ($20, for example) you pay for a covered health care service after you’ve paid your deductible.
Let’s say your health insurance plan’s allowable cost for a doctor’s office visit is $100. Your copayment for a doctor visit is $20.
- If you’ve paid your deductible: You pay $20, usually at the time of the visit.
- If you haven’t met your deductible: You pay $100, the full allowable amount for the visit.
Copayments (sometimes called “copays”) can vary for different services within the same plan, like drugs, lab tests, and visits to specialists.
Generally plans with lower monthly premiums have higher copayments. Plans with higher monthly premiums usually have lower copayments.
The maximum amount a plan will pay for a covered health care service. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”
If your provider charges more than the plan’s allowed amount, you may have to pay the difference.
When a provider bills you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services.