It's almost a conspiracy.
How many confusing terms can the health insurance industry come with unique to this product.
It can occasionally feel that way but we're here to break up the cabal and put a little power in the California health insurance shopper's hands. Enter exhibit 1...Deductible.
So what exactly is a deductible and why has it become almost the deciding factor when choosing health insurance in California.
We'll try to keep our discussion in layman's terms so it's easy to wrap your head around yet another insurance term.
A deductible is an amount that you must pay first before getting help from the insurance carrier.
A quick caveat there...if you're on a PPO plan (most of us are these days)
and you use in-network providers, you'll get an immediate benefit in the form of
the negotiated PPO discount which usually brings the total cost down 30-60%. You
would then pay this discounted rate until you have met your deductible. An
example always helps.
Let's say that you have a $500 deductible and you need a small procedure that will cost $2000 (the negotiated rate).
You would pay the first $500 as your deductible. With most plans, you would then go into your coinsurance benefit (a percentage usually like 70/30) where you would pay 30% (in our example) of the remaining $1500 ($2K-$500 deductible).
The deductible resets every Jan 1st regardless of when you started the plan as it happens with other main health insurance parameter (max out of pocket, etc).
Once you meet your deductible for a given situation, it applies to other covered health issues during the remainder of the calendar year.
Each incident does not have it's own deductible. If you have a family or two more people on one policy, each person would have their own deductible with most plans up to two people.
This means that if you had catastrophic bills for 5 family members, you would not need to meet 5 separate deductibles...only two.
The HSA (Health Savings Account) plans in California are a little different in that all covered benefits including office visit copay and medication are subject to the main deductible.
With most other PPO and HMO plans, you get some number of office visit copays and RX copays before meeting the main deductible although brand name RX usually has its own separate deductible.
On the California individual health insurance market, brand deductibles usually run from $0-$5000 depending on the plan .
They are less on the Group health market and generally run $0 to $1000 on average.
As for main plan deductibles, those usually run from $1K-$6K for individual family and $0-$1K for group. There's been a steady increase in the deductible levels to offset further rate increases but that reversed significantly (on both fronts) Jan 1st, 2014 with Health Reform.
The Health Reform bill mandates a certain level of benefits which will figure into the available deductible amounts.
Here are general ranges for the deductible by Plan type:
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