Does Insurance Cover Anything Before the Deductible?

The deductible is one of the most important parts of an insurance plan to understand. It refers to the amount you must pay out-of-pocket for covered health services before your insurance kicks in to start sharing costs. With a $2,000 deductible, for example, you would need to pay the first $2,000 of medical care expenses yourself before your insurance starts paying its share.

Many people assume that until they meet their deductible, their health insurance coverage pays nothing. But this isn’t necessarily true. There are some common health services and types of preventive care that your insurance might provide with no out-of-pocket costs, even before you hit your deductible amount.

Preventive Care

One major category of health services that insurance plans often cover fully before the deductible is preventive care. This refers to routine health screenings, checkups, and immunizations meant to prevent illness and catch problems early.

Examples of preventive care services that insurance plans must cover at no cost to you include:

• Annual wellness visit with your primary care doctor
• Screenings for cancer, diabetes, high cholesterol, high blood pressure, depression, and other conditions
• Vaccinations like flu shots, HPV vaccine, measles-mumps-rubella (MMR) vaccine
• Counseling for smoking cessation, losing weight, etc.
• Women’s preventive services like mammograms, pap smears, prenatal care

The Affordable Care Act (ACA) requires all health plans to provide full coverage for recommended preventive services, without applying deductibles or copays. This applies to plans purchased through the Health Insurance Marketplace as well as most employer-sponsored plans.

By getting preventive care covered at no cost to you, you can maintain your health while avoiding bigger medical bills down the road if illness occurs.

Other Common Exceptions to the Deductible

In addition to preventive care, health insurance plans often cover some other types of services before you meet your deductible. While these are not required to be covered like preventive care, they are common exceptions. Some examples include:

Primary and Urgent Care Visits

Your insurance plan may provide a set number of primary care doctor and urgent care visits at a copay or discounted rate before the deductible. For example, the plan may cover your first 3 primary care visits for a $30 copay each. Any visits after that would apply to the deductible.

Covering some initial primary/urgent care makes it easier for you to get basic healthcare and monitoring without expensive bills to start off your plan year. This encourages you not to delay needed care because of cost.

Prescription Drugs

Many health plans apply a separate, lower deductible specifically for prescription medications. For instance, you may have a $2,000 overall deductible but only a $200 deductible for prescription drugs. This lets you get medications at reduced cost without having to meet the full deductible first.

Some plans also cover certain generic drugs with just a copay, even before hitting the prescription deductible amount.

Mental Health Services

Your health plan may offer a number of initial mental health visits and/or counseling sessions for a copay before the deductible applies. Having affordable access to this type of care can be extremely valuable for managing conditions like depression, anxiety, addiction, and more.

Lab Tests and Imaging

Diagnostic services like lab tests, x-rays, and MRI scans might be discounted or covered with a copay for you before meeting deductible requirements. This makes it easier to get needed tests to diagnose health issues early on.

How to Find Out What Your Plan Covers

To confirm which services your specific health insurance plan might cover before deductible, be sure to:

• Check your plan documents – The Summary of Benefits and Coverage (SBC) outlines your cost shares for different categories of benefits. Look this over or call your insurer if you have questions.

• Log in to your insurance website/app – This will show current deductible status and how much you owe for various healthcare services.

• Ask your doctor – When scheduling appointments, ask the doctor’s office to confirm with your insurance how much you will owe out-of-pocket based on your deductible status.

• Use in-network providers – Any pre-deductible coverage generally only applies when using doctors, facilities, pharmacies, etc. that are in your plan’s network. Going out-of-network likely means you pay the full cost until meeting the deductible.

Being strategic and utilizing pre-deductible services when possible allows you to maximize your coverage and savings on healthcare costs throughout the year.

Preventive Care Details and Recommendations

As discussed above, one of the biggest categories of pre-deductible health services are preventive care screenings and immunizations. It’s valuable to understand exactly which types of preventive care are recommended based on your age, health status, and risk factors:

Children & Adolescents

• Newborn screenings – Testing for hearing, heart defects, jaundice, and other conditions

• Regular well-child visits – Include growth monitoring, developmental checks, vision and hearing tests, immunizations

• Immunizations – Varies by age, but includes vaccines for polio, MMR, chickenpox, hepatitis, flu, HPV, meningitis

• Screenings – May include cholesterol, lead, tuberculosis, sexually transmitted infections

Adults

• Annual wellness visit – Preventive care consultation with PCP, includes health risk assessment

• Screenings – Varies by age, but may include cholesterol, diabetes, HIV, colorectal cancer, osteoporosis, depression

• Immunizations – Flu shot annually; tetanus booster every 10 years; shingles vaccine at age 50+

• Counseling – On diet, exercise, smoking cessation, STIs, domestic violence, and other safety/lifestyle issues

Women’s Health

In addition to the general adult guidelines, women need:

• Contraceptive methods – All FDA-approved birth control options like pills, IUDs, implants covered without copays

• Breast cancer screening – Mammograms every 1-2 years for women 40 and older

• Cervical cancer screening – Pap smears every 3 years ages 21-65

• Prenatal care – Includes routine doctor visits, screenings, vaccinations during pregnancy

Other Key Recommendations

People with certain risk factors or conditions need more frequent or earlier screening:

• Colon cancer – Earlier screening for those with family history or other risks

• Diabetes – Earlier and more frequent cholesterol, kidney function checks

• Heart disease – EKG, stress test for those at risk

• Osteoporosis – Earlier bone density scans if risk factors present

Talk to your doctor about what preventive services are right for you based on health history and age. Take advantage of these screenings covered before deductible!

Frequently Asked Questions

Can I get a physical exam before meeting the deductible?

Yes, annual wellness visits with your primary care doctor fall under preventive care that policies must cover in full. This includes health/family history review, checking height, weight, blood pressure, vision screenings, and discussing appropriate preventive care needs.

Does my insurance have to cover brand name prescription drugs before the deductible?

No, the Affordable Care Act requires plans to provide free preventive services, but not prescription drug coverage specifically. Your plan may have a separate prescription deductible or copays for generics, but brand drugs are typically subject to the general plan deductible.

What if I’m not sure if a test or service falls under preventive care?

When scheduling appointments, ask the doctor’s office to confirm with your insurance whether it will be covered as preventive or subject to the deductible. You can also call the member services number on your insurance card to find out how a service will be billed.

Can I still get preventive care from out-of-network providers?

Typically you need to see in-network providers for services to be covered in full before deductible. But for specific preventive services, the ACA requires coverage even if you are out-of-network, at no charge or deductible. These include immunizations and breast cancer screening.

Do I still have to pay copays for office visits before deductible?

It depends. Wellness exams are covered fully, but if you are treated for a health issue at the same preventive care visit, the office visit copay may still apply along with any other costs before deductible. Check with your insurer.

The Takeaway

While you’re responsible for health costs up to the deductible amount, many insurance plans provide certain exceptions and cover services earlier. Especially key are preventive care screenings and immunizations recommended for your age and risk factors, as the ACA requires their full coverage. Check your plan details