Your deductible is the amount of money you pay out-of-pocket for covered health care services before your insurance company pays anything. There is a caveat. Thanks to the Affordable Care Act (also known as the ACA or Obamacare), certain preventive services usually are not subject to a deductible.
Your deductible is what you must pay before insurance covers anything. After you meet your deductible, you pay coinsurance until you reach your out of pocket maximum. Once you reach your out of pocket maximum, all covered expenses are paid by your insurance.
If your deductible has been satisfied, your health insurance will pay for the service, minus any copayment or coinsurance you are required to cover. If the deductible has not yet been satisfied, you are responsible to pay for the services received—this is your contribution toward the deductible.
The service might not be covered by the health plan, or the health plan might require specific procedures to be followed in order to have coverage (a referral from a primary care physician, for example). Depending on the health plan, care might only be covered if the medical providers are in-network.
Health insurers deny claims for a wide range of reasons. In some cases, the service simply isn't covered by the plan. In other cases, necessary prior authorization wasn't obtained, the provider wasn't in-network, or the claim was coded incorrectly.
A deductible is the amount you pay for coverage services before your health plan kicks in. After you meet your deductible, you pay a percentage of health care expenses known as coinsurance. It's like when friends in a carpool cover a portion of the gas, and you, the driver, also pay a portion.
According to the analysis, AvMed and UnitedHealthcare tied for the highest denial rate, with both companies denying about a third of in-network claims for plans sold on the Marketplace in 2023, respectively.
People without insurance pay, on average, twice as much for care. This means when you use a network provider you pay less for the same services than someone who doesn't have coverage – even before you meet your deductible.
Until you reach your deductible, you'll pay for 100% of out-of-pocket costs. After you meet your deductible, you and your insurance company each pay a share of the costs that add up to 100 percent.
It is entirely due to the rates negotiated and contracted by your specific insurance company. The provider MUST bill for the highest contracted dollar ($) amount to receive full reimbursement.
Your healthcare provider can't waive or discount your deductible because that would violate the rules of your health plan. But they may be willing to allow you to pay the deductible you owe over time. Be honest and explain your situation upfront to your healthcare provider or hospital billing department.
Remember that filing small claims may affect how much you have to pay for insurance later. Switching from a $500 deductible to a $1,000 deductible can save as much as 20 percent on the cost of your insurance premium payments.
Once a person meets their deductible, they pay coinsurance and copays, which don't count toward the family deductible.
While it is not illegal to self-pay if you have insurance, we always encourage individuals to have the right health plans to ensure they are prepared for significant medical expenses. Still, we know that there are times when it does not make sense to file a claim with the insurance company.
Investopedia's analysis ranks Kaiser Permanente as the best health insurance company for 2025 because of its blend of affordability and low customer complaints. UnitedHealthcare and Aetna also earned top marks.
Key takeaways
Amica and USAA tied in Bankrate's analysis as the two best auto insurance companies overall. Geico ranks as the best car insurance company for high-risk drivers. Nationwide and Liberty Mutual are some of the best auto insurance companies for discounts and bundling.
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.
PPOs Usually Win on Choice and Flexibility
Unlike most HMO health plans, you won't likely need to select a primary care physician, and you won't usually need a referral from that physician to see a specialist.
Coinsurance – Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. You pay the coinsurance plus any deductibles you owe. If you've paid your deductible: you pay 20% of $100, or $20. The insurance company pays the rest.
A plan that has a deductible of at least $1,400 (for individuals) or $2,800 (for a family) is considered a high-deductible plan. If your insurance plan has a low deductible, this means you may reach the threshold earlier and get cost-sharing benefits sooner.
A waiting period deductible is a provision in an insurance contract that specifies a period during which the policyholder must cover the cost of care or loss before the insurance benefits take effect. Insurers use this to avoid small claims and promote responsibility among policyholders.
Uninsured families pay for a higher proportion of their total health care costs out of pocket than do insured families, however, and are more likely to have high medical expenses relative to income (IOM, 2002b).