A deductible is the amount you pay for covered care each plan year before your health plan starts paying its share. Until you reach it, you pay the full cost of covered services that are subject to it, and in network that cost is the plan’s allowed amount, not the provider’s list price. After it, you pay copays or coinsurance and the plan pays the rest. The count starts again at zero when a new plan year begins.

Cost sharing runs in a fixed order. First the deductible, for services subject to it. Then copays, which are flat amounts, or coinsurance, a percentage of the allowed amount, with the plan paying the remainder. Last the out-of-pocket maximum: once your deductible, copays and coinsurance reach it, the plan pays 100% of covered in-network care for the rest of the plan year. Premiums sit outside this sequence and count toward none of it.

The part people get wrong is assuming every service waits behind the deductible. Preventive care delivered in network does not: it carries no cost sharing and no requirement to meet the deductible first. Many plans also charge a flat copay for primary care visits or generic drugs from the first day, leaving the deductible untouched. The reverse error costs money too, because the preventive exemption depends on why a service was ordered. The same test ordered as routine screening is preventive; ordered to monitor a diagnosed condition, it is diagnostic, and normal cost sharing, deductible included, applies.

You meet the deductible when choosing a plan, beside the premium on the NY State of Health comparison screen or in an employer’s plan summary. Bronze plans carry the lowest premium and the highest deductible, so the monthly price and the price of using care move in opposite directions. You meet it again on an explanation of benefits, where the patient responsibility line shows what went toward it, and at the pharmacy counter or front desk early in a new plan year, when something that cost only a copay last month costs the full allowed amount. That jump is usually the reset. Check when your plan year starts before you dispute it.

In New York: several rules take the deductible out of the picture. Medicaid and the Essential Plan have no deductible at all and a $0 premium, and both accept applications in any month; the application decides which one you land in. On plans the state regulates, prescription insulin has carried no cost sharing since January 1, 2025: no deductible, no copay, no coinsurance. That includes high deductible health plans, with individual catastrophic plans excepted. A law signed November 24, 2025 does the same for at least one rescue and one maintenance asthma inhaler, but the state’s announcement gave no implementation date, so ask your plan when it reaches your policy. The insulin and inhaler rules stop where state regulation stops. They reach individual plans bought through NY State of Health, small group plans and fully insured employer plans. They do not reach a self-funded employer plan, where the employer pays claims from its own money under federal law, or Medicare Part D. The insurance card does not say which kind you have; HR does. A high deductible has one more consequence here: if your out-of-pocket medical costs over 12 months exceed 10% of gross income, the state’s hospital financial assistance law treats you as underinsured and caps what the hospital may charge.

  • If you use care regularly, compare deductibles before premiums, and ask the marketplace whether you qualify for cost-sharing help and which plans it applies to.
  • Before a test or screening, ask whether it is being ordered and coded as preventive or as diagnostic.
  • If a pharmacy applies your deductible to insulin on a state-regulated plan, ask it to re-run the claim, then write to the plan. The Department of Financial Services takes complaints at 800-342-3736. Insulin in New York.
  • Ask HR whether your plan is fully insured or self-funded. Why the answer decides which rules apply.
  • If a year of deductible, copays and coinsurance passes 10% of your gross income, apply for hospital financial assistance as an underinsured patient.

Also called: annual deductible, plan deductible. Full guide: Buying coverage on NY State of Health. Reference: Deductible on Wikipedia — general definition, not New York specifics.

More in Glossary of health coverage and billing terms

  • Allowed amount — The number a plan treats as the price of a service, which is almost never the number on the bill and is what your percentage share is actually taken from.
  • Tax household — The group whose income is counted together for coverage eligibility, decided by who files a tax return with whom rather than by who lives in the apartment.
  • Qualified health plan — A plan certified for sale on a health insurance marketplace, which guarantees a floor of benefits and protections and tells you nothing about the network.
  • Copay — A copay is a fixed amount you pay for a covered service. How it differs from coinsurance, when the deductible comes first, and the copay rules New York adds.
  • Out-of-pocket maximum — The out-of-pocket maximum caps your cost sharing for covered in-network care each plan year. What counts toward it, what never does, and the New York rules.
  • Preventive care — The category of services a plan must cover with no cost sharing, and the reason a 'free' screening sometimes arrives with a bill.
  • Insulin Costs Nothing in New York Now. If You Are Being Charged, Here Is Why — Since January 1, 2025 New York bans all cost sharing on prescription insulin: no deductible, no copay, no coinsurance. Which plans it covers, which it does not, and what to say at the counter.

This page explains how the system works. It is not medical advice. More.