Health Care You Can Get Without Paying Your Deductible

Nurse taking patients blood pressure
Thinkstock Images/Stockbyte/Getty Images

If you’re struggling to find room in your budget for large monthly health insurance premiums, learning that you have to pay a yearly deductible before your health insurance pays your medical bills can feel like the last straw.

Since deductibles can be from several hundred dollars to a few thousand dollars, it may seem like you’ll never use enough health care services to meet your deductible; your health insurance won’t really pay for anything.

Don’t cancel your health insurance policy yet. You’ve misunderstood.

Most health insurance plans pay for some health care services even before you’ve paid your deductible. Although each health plan is different, there are some common themes about what health care you can get without paying your health insurance deductible.

Preventive Care

You’ll likely get preventive care without paying your health insurance deductible. All non-grandfathered, comprehensive health insurance plans sold in the United States have to cover preventive health care services without requiring cost-sharing from you. That means you won’t have to pay your deductible, a copay, or coinsurance for preventive care like your yearly physical, screening mammogram, or routine vaccinations.

A word of caution, if your health plan is a managed care plan like an HMO, PPO, or EPO, you’ll have to get your preventive care in-network if you don’t want to pay your deductible first.

If you get preventive care from an out-of-network provider, your health insurance can require you to pay part of the cost.

Copayment-Only Vs Copay After Deductible

In some health plans, without paying your deductible you can get all the health care services that require a copayment. All you pay for those services is the copayment even if you haven’t met your deductible for the year.

However, other health plans require you to pay the full deductible for all non-preventive care. For those plans, only after you’ve met the deductible do copayments and coinsurance kick in.

Here’s an example of what you’d pay for the same problem in each health plan type. Health Plan A is a “copayment only” type plan; you pay only the copayment even if you haven’t met your deductible. Health Plan B is a “copay after deductible” type plan; you first pay the entire deductible and then the copayments kick in.

 Health Plan AHealth Plan B
Cost-Sharing Requirements

$1,000 deductible,

$40 copay for MD visits

$1,000 deductible,

$40 copay for MD visits

You get the flu in January before you’ve met your deductible. The MD bill is $120.  
You pay$40 copay$120
Health insurance pays$80 (The remainder of the doctor bill.)$0 (Because you haven't met your deductible yet.)
You get sick in November after you’ve met your deductible. The MD bill is $120.  
You pay$40$40
Health insurance pays$80$80

In health plans structured like Health Plan A, you can get many health care services without having to pay your deductible.

How do you know whether your health plan works like Health Plan A or like Health Plan B? Read your Summary of Benefits and Coverage carefully. Pay close attention to the examples. Phrases like “copay after deductible” imply you have to pay the entire deductible before copayments kick in. If it’s not clear from reading the health plan literature, call the customer service number on your health insurance card and ask.

3 Primary Care Visits With Catastrophic Health Plans

If you have catastrophic health insurance you bought through your state’s Affordable Care Act health insurance exchange, you’re allowed three visits with your primary care physician each year without paying your health insurance deductible. Like more standard health plans, your catastrophic plan also covers 100% of in-network preventive health care without having to pay your deductible.

Do You Qualify for Catastrophic Health Insurance?
6 Things to Know About Catastrophic Health Insurance
How To Make a Budget for Health Care Expenses

Sources

Catastrophic Health Care Plans on HealthCare.gov accessed on 1/26/2015.
Free Preventive Care on HealthCare.gov accessed on 1/26/2015.

Continue Reading