What counts toward the health insurance insurance deductible: the amount that the medical provider billed the insurance, or the amount that the insurance billed the patient?

For example:

  • the medical provider billed the insurance 200 USD
  • the insurance negotiated it for 50 USD, and, assuming that the deductible hasn't been reached yet, subsequently bills the patient pay 50 USD

Would 50 USD or 200 USD count toward the health insurance deductible?

  • Please check your policy. In some policies, your co-pays ($20/visit, etc.) do not count towards your deductible amounts. – mkennedy Feb 24 '19 at 0:20
  • @mkennedy copay = The specific dollar amount or percentage required to be paid by the patient. If the copays do not count towards the patient's deductible amounts, then what counts toward it? – Franck Dernoncourt Feb 24 '19 at 6:27

This is a small nuance but insurers don't bill the insured.

An insurer will issue what's called an Explanation of Benefits (EOB). The EOB will have an illustration of the billing, including:

  • a billed amount,

  • a negotiated revised billed amount (also known as the "contracted rate" or "allowed amount"),

  • then cost sharing with an insured's cost share based on the specific plan,

  • your deductible and out of pocket maximum accruals.

Generally, your deductible, unless your plan is grandfathered which is rare at this point, will capture any spending by the insured toward covered benefits. In your example the $50 would apply toward the deductible, assuming an in-network provider.

If this was an out-of-network provider, you would also potentially owe the $150 (the difference between the $200 billed amount and the $50 insurance carrier determined allowed amount). That $150 "balance bill" won't be considered by your insurer for any cost sharing accrual, generally.

Part of the contracts that in-network providers agree to includes a prohibition on balance billing; making it a non-issue.

  • Lately, many plans I have seen or considered have had separate deductibles and OOP max amounts for in-network vs. out-of-network, in which case the "won't be considered for any cost-sharing accrual" part would be only partially true. – Wesley Marshall Feb 21 '19 at 4:43
  • @WesleyMarshall balance billing never accrues because the insurer doesn't recognize it. It has nothing to do with different limits for in and out of network. – quid Feb 21 '19 at 7:03
  • You're right, of course. I misread your sentence the first time around. – Wesley Marshall Feb 21 '19 at 14:10

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