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California health insurance  -  California health coverage basics  -  Understand deductible and out of pocket max

How to Compare the Deductible and Out of Pocket Maximum When Quoting

When you first run your California health quote for individuals and families, it's easy to glaze over and just look for the highlights. Of course, premium is high (if not highest) on this list. People also tend to look focus on copays whether for office visits or RX coverage but in order to really make a good decision, we need to understand how the different carriers reflect the true out of pocket exposure for the really big bills. Unfortunately, the carriers can have very different ways or showing this information and the quoting engines ultimately just reflect what the information according to the carrier which doesn't help the consumer much. Let's take a look at the most critical example of this when it comes to the deductible and max out of pocket.

First, a quick review of both deductible and max out of pocket

The deductible is the amount you will pay for medical expenses (at the discounted PPO rate if in network and on a PPO or HSA plan) before the carrier starts to help.

After the deductible is met, you will then usually pay a percentage (say 40%) of remaining bills until you hit the maximum out of pocket or OOP (out of pocket max) which are two different ways of saying the same thing. For most plans, the carrier will pay 100% of covered benefits, in-network once the OOP is met. That makes the OOP a really important concept and number since health insurance is quickly becoming about protecting from really big medical expenses (also called catastrophic) as rates have spiraled (along with deductibles/OOP's) over the past decade. So that's our review. Now let's look at how the carriers might reflect this information in their benefit summaries.

Deductible as part of Max out of Pocket

ACA UPDATE:  All Max out of Pockets now include the deductible for ACA compliant plans

 Let's give an example to simplify all the jargon. Let's say you have a $2000 deductible. After the deductible, you will pay a percentage (the coinsurance mentioned above) of 40% for another $4500. Your total out of pocket is really $6,500 if you get a $20K bill of covered medical expenses.

So how do we proceed?

Our quoting engine shows both deductible and OOP in the summary page which is important. Some of the biggest (if not the biggest) health insurance websites on the web will only show you the deductible which is misleading. There are plans that have deductibles of $2500 and OOP's of $5K. If you only see the deductible, it looks priced really well unless you understand that the real OOP is $7500 (a big number). You need to know both to make an informed decision.

In the end, you can always click on the plan name while running your California health insurance quote to get more detail and even access to brochure which will spell out whether the OOP includes the deductible. Of course, you can always go through the plans with us and we'll quickly be able to size up the best value while taking into account this accounting trick of deductible/max benefits.

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