PPO Insurance and Plans - How Deductibles Work

Simply put, PPO means you can go see anyone within that company's network, without needing a referral. So if you are looking to see if your doctor is in a particular network, you should ask your agent before you buy health insurance.

Now before you buy a health Insurance plan, an incredibly important question you MUST ask BEFORE you buy is how does the deductible work? This is such a neglected question, but very important to understand.

With Health Insurance, a Deductible (the first stage) is the amount of money that you pay out of your pocket before you move into the 2nd stage. So in the first stage, pay attention to the details of how much you'll pay for small procedures if you only pay parts of your deductible in a year, but not the entire deductible.

Now if you have met your Deductible, you'll move into the"Co-Insurance" stage. In this 2nd Co-Insurance stage, you and your insurance company will 'co-insure" meaning, you and your insurance company will share the burden of the bill. You will generally pay the lesser percentage, and the insurance company will pay the larger portion.

Then the 3rd and final stage of insurance is "Maximum Out Of Pocket." This is the most you'll have to pay in a calendar year.

What happens before the deductible is met is where company's can vastly differ. For example, if you have a $5,000 expense from an Emergency Room, and you have a $5,000 deductible, and you haven't yet "met your deductible," how much would you expect to pay? Is the insurance company going to share with you a negotiated rate? If they do, get specific, how much of a discounted rate will they will give you? Dig deeper, get your straight forward answer. Is it a percentage? Is it a range?

For Example:

* Scenario 1 - $5,000 Emergency Room Kidney Stones Bill, Deductible $5000, your out of pocket $2,000

* Scenario 2 - $5,000 Emergency Room Kidney Stones Bill, Deductible $5000, your out of pocket $5,000

Always ask how many deductibles you must meet each year. This can vastly differ within different company's and different plans. Are you a single individual or family? Ask how many total deductibles there are per calendar year... per person and per family.

Deductibles usually range from $500 - $10,000 in private insurance plans. The higher the deductible, the lower the premium, and conversely the higher the premium, the lower the deductible.

The rationale behind this is that if the Insured person is willing to pay a little more each month in their premium, the insurance company can reduce their deductible, but if the client would prefer to have a low premium and take on a little higher risk with total money out of pocket, they exchange that risk for a lower premium.

If you have ppo insurance with Co-Pays, generally you'll pay a "Co-Pay" at the Dr's office, without having to worry about a deductible, however, you MUST ask questions when shopping for health coverage. Some "Co-Pays" are after the deductible has been met, for example, if your plan says an Emergency Room "copay" of $100, is this before or after the deductible?

So to sum up deductibles, it is the amount of money that comes out of your pocket before the insurance company will begin to split the bill with you (co-insurance). Again, ask questions. BEFORE you've met your deductible, are you getting a network discounted rate, and if you are, WHAT IS IT?