Is It Legal to Self-Pay If You Have Health Insurance? | eHealth

Generally speaking, the point of having health insurance is to use it when you’re sick or need to see the doctor. however, there are some times when it may make sense to pay for medical care out of pocket instead of. use your health insurance coverage.

So, in these times when it seems like it’s best not to use your insurance plan, is it possible? If so, what situations require you to pay directly or by other means? another critical question to answer would be, “is it illegal not to use your health insurance?”

Reading: Is it legal to self-pay when you have insurance

This guide is an essential resource if you are interested in the legalities of not using health insurance for a medical procedure, a simple primary care visit, or different medications.

Is it illegal not to use your health insurance?

Health care coverage is a pressing issue today and can affect the economy by affecting wages, job growth and overall business growth. Lawmakers sought to resolve or alleviate the problem by introducing the Affordable Care Act (ACA), which was passed in 2010. The primary goal of this law was to increase Medicaid eligibility for more low-income people and their families. this law certainly made health insurance coverage more affordable.

However, citizens needed to obtain health insurance. otherwise, people would have to pay a fine. This regulation changed when the tax penalty obligation for health insurance was removed in January 2019. As a result, individuals did not have to pay a tax penalty for failing to provide health insurance for themselves or their families.

many states have eliminated the penalty for those who seek medical services without insurance plans. this means that it is not illegal not to use your health insurance for medical services. Medicare patients may have different requirements.

Patients may choose to pay for medical services if it is in their best interest to pay directly. So now that you know you can pay for yourself if you have insurance, let’s learn more about when it makes sense to do so.

when would it not make sense to use your health coverage?

Health coverage is essential in many different situations because a comprehensive policy can help you avoid high out-of-pocket costs. however, there are some cases where paying with your own funds may be more beneficial than using your health coverage.

See also: Can you use life insurance to build wealth? | Insurance Business America

Now that you know it’s legal to pay yourself when you have insurance, here are some situations where it may make sense to pay directly for the medical procedure or service without filing a claim with your provider.


1. when the year of the deductible is about to end and you are far from meeting it.

This is one of the main reasons for opting out of your health insurance plan. deductibles often reset annually, so it may make sense to pay cash if you need to see a doctor toward the end of the year, especially since you’re nowhere near meeting your deductible.

It’s crucial to find out how much you should pay if your insurance handled the claim. then find out how much your medical provider would charge you for the service you need if you had to pay cash. Finally, ask if discounts are available for paying in advance. This will help you see a clear difference in your insurance costs. you may even want to shop around as a “cash customer” to compare prices.

Sometimes paying cash is less expensive than processing the claim through the insurance provider. however, keep in mind that money you spend out of pocket won’t count toward your deductible when you don’t use your health insurance to pay for health care.

2. when you’ve decided you want to see an out-of-network provider.

Out-of-network providers may cost you more depending on your insurance policy. In fact, some health plans don’t cover out-of-network providers at all, while others may give you a lesser amount of coverage when you see out-of-network providers. this means you may not get the care you need and you may have to pay out of pocket.

Depending on your plan, it may be of little use to have your insurer process the claim if you’ve decided you want to see an out-of-network health care provider. be sure to ask the medical provider for a discount as a cash customer. many will give you one.

3. when you can find a better price for your prescription drug needs.

Some health insurance policies offer reasonable copays for prescription drugs. however, others may require you to meet a hefty deductible before the insurer begins to pay for your prescriptions.

See also: How long can I drive my new car without insurance? |

If you’re facing a high deductible, you may want to consider paying for certain medications out of pocket instead of having your insurance company process them. this can be especially helpful if the deductible year is coming to an end.

Out-of-pocket expenses will not count toward your annual deductible. however, you may occasionally be able to get a better cash price than you would have to pay when your insurance processes the claim. this means you can get more medicine for less.

paying yourself versus using your health insurance

Health care coverage is essential because it can help you account for unexpected events and significant medical expenses. Large medical expenses can substantially affect your financial and mental health. health care coverage can help you avoid medical debt and ensure your health is taken care of.


While it is not illegal to pay out of pocket if you have insurance, we always encourage people to have the right health plans to ensure they are prepared for significant medical expenses.

still, we know that there are times when it does not make sense to file a claim with the insurance company. it is a personal choice to use or waive your coverage policy. can be a great option if you think doing so is in your best interest.

The healthcare and insurance landscape right now can seem complex. having the right partners and resources to navigate is even more critical. If you need help with health care coverage options or need more information about deductibles, explore the eHealth platform or contact one of our insurance agents today.

one final warning:

The examples above are examples only. Decisions like this are personal in nature. We generally don’t recommend that people not use their coverage to avoid paying their deductible, but we recognize that there are times when it can make financial sense. The fact is that you never know when someone serious could happen. if so, you’ll be glad for every dollar you’ve already contributed to your deductible.

See also: Cancel Your Foresters Financial Life Insurance Policy Online or by Phone | QuickQuote®

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