What’s the Difference Between Deductible vs Out-of-Pocket?

It can be unclear how your health insurance works, especially if you have a family covered by your policy.

There can be many restrictions, guidelines, limitations, and rules about your coverage, and those can change each year when your insurance plan renews or you switch plans. 

You’re most likely familiar with health insurance premiums—the payment you make each month to your insurance company.

But your financial responsibility for your healthcare doesn’t end with your premiums.

You’ll need to try to plan for other expenses, including your deductible and the costs of your healthcare up to your out-of-pocket maximum.

While preparing for healthcare expenses may not be realistic, especially if you have young children, it’s a good idea to estimate what you’ll spend on medical care based on past years’ expenses.

In this article, we’ll discuss what a health insurance deductible is and how an out-of-pocket maximum works.

Then, we’ll go over the difference between your deductible and out-of-pocket expenses and how they’re connected. Finally, we’ll explore some ways to save on your healthcare costs.

Health Insurance Deductible

A health insurance policy deductible is the amount you’ll pay out of pocket for covered medical expenses before your provider begins to pay for them.

So, suppose your deductible is $2,000. In that case, you’ll need to spend $2,000 on services included in your coverage before your insurance will cover any portion of your expenses.

Generally speaking, the higher your insurance premium, the lower your deductible.

Out-of-Pocket Maximum

The out-of-pocket maximum for health insurance is the most you’ll have to pay before your insurance covers 100% of your medical expenses and bills.

The federal government sets the out-of-pocket maximum, which, in 2022, can be no more than $8,700 for individual plans and $17,400 for family plans.

This maximum amount applies to all levels of health insurance coverage, whether you get it through an employer, the insurance exchange, or a licensed private broker.

Even though the out-of-pocket maximum might seem high, it can significantly benefit families.

For example, suppose someone has a long-term illness or the sudden onset of a medical problem that requires extensive care, tests, surgery, or hospitalization.

In that case, this maximum out-of-pocket cost can be met quickly.

The security of knowing that a severe illness or injury won’t bankrupt you is worth the monthly premium expense.

Deductible vs. Out-of-Pocket Costs

It’s essential to understand the difference between your deductible and out-of-pocket maximum.

However, it may be confusing, since spending money to meet your deductible is an out-of-pocket cost as well.

It’s also helpful to know how your deductible works with your out-of-pocket expenses.

How they work

Your deductible is met by paying for specified services out of pocket to reach your deductible amount, which is based on the insurance policy you have.

Once you’ve met your deductible, your insurance then covers the agreed-to percentage, and you’re still responsible for your portion of the bill.

Each type of insurance is designated by the Affordable Care Act (ACA) marketplace as a metal, and each metal covers a different percentage of your care after your deductible is met:

• Bronze: Your insurance pays 60% of your medical bills, and you pay 40%.
• Silver: Your insurance pays 70% of your medical bills, and you pay 30%.
• Gold: Your insurance pays 80% of your medical bills, and you pay 20%.
• Platinum: Your insurance pays 90% of your medical bills, and you pay 10%.

Once you meet your deductible, you’ll continue paying your portion for healthcare until you reach your out-of-pocket maximum.

Once you reach that limit, your insurance company will pay for 100% of your in-network medical expenses.

For the majority of insurance coverage, the lower your percentage of responsibility for your bills, the higher your insurance premium—and the higher your premiums, the lower your deductible.

In addition, your out-of-pocket expenses and your deductible will reset each calendar year when you renew your insurance plan or choose a different one.

Differences

Although your deductible and out-of-pocket expenses are all part of the price you pay for health insurance, they do have some differences:

• Your deductible will vary depending on what type of insurance you have. Still, the maximum out-of-pocket expenses will be the same no matter your coverage, as mandated by the ACA. 
• Your out-of-pocket expenses include your deductibles, copays, and coinsurance payments. However, your out-of-pocket costs don’t include your monthly health insurance premiums, and they don’t include any medical bills for out-of-network care.
• Your coinsurance goes towards your deductible, but non-covered prescriptions, out-of-network doctors or treatment, and any over-the-counter medications don’t count towards your deductible amount.

What applies to each

How to Save on Healthcare Costs

Enroll in a health savings account (HSA)

You can contribute pre-tax dollars to an HSA and use the money to pay for qualified medical expenses.

Also, the money in your account can be invested to earn interest and grow through stocks, bonds, and mutual funds.

Track your expenses for your taxes

If your medical expenses add up to more than 7.5% of your gross income, you may be able to take a tax deduction.

Choose outpatient care if it’s an option

Some procedures can be done on an outpatient basis instead of needing an overnight stay in the hospital, which is often expensive.

Check with your doctor to see if a treatment you need can be done this way.

Always use in-network providers

Before seeing any new doctor or other practitioners, make sure they’re covered as a provider on your insurance plan—otherwise, you’ll be responsible for the entire bill, which could come as an unwelcome surprise.

Your insurance company will have a list of providers on their website who are covered under your plan, or you can contact the customer service department for help.

Check your prescription medication options

You can lower your medication costs in a few ways:

• If possible, choose generic over a brand name for your prescriptions.
• Sign up for a delivery prescription service that discounts larger prescription orders.
• Ask your doctor to write your prescriptions for three months at a time instead of one.

You can also ask your doctor if an over-the-counter medication would work instead of the prescribed medication.

However, don’t ever skimp or cut back on a prescription to save money, as that could severely reduce the effectiveness of the medicine.

Purchase catastrophic coverage

If you are relatively healthy and expect to remain that way, catastrophic coverage may be a good option for you.

This type of coverage offers very low premiums with a very high deductible.

This is best for a young, single person who has no children or medical conditions.

How K Health Can Help

Need to go to urgent care but don’t have insurance? 

Check your symptoms, explore conditions and treatments, and if needed, text with a healthcare provider in minutes all through K Health. 

K Health’s AI-powered app is based on 20 years of clinical data.