The breakdown of a typical health insurance plan design

For those with health insurance currently....Let the shoppe ask you a question.

What is your deductible?  If it took you longer than 10 seconds to come up with a "maybe" response or no response at all...then read below.

Every plan of health insurance will have two key common components.  A deductible(1) and out-of-pocket(2), which when combined, equal your true exposure to risk in a calendar year.

The Deductible is the amount of money that you must spend before the insurance company will begin to pay a percentage of further claims.  Please note that the final costs you pay towards the deductible are on the negotiated rate of service between the insurance carrier and provider.

The Out-of-Pocket (OOP) is the remaining amount that you must pay after the deductible before the insurance company will begin to pay 100% on future claims for the remaining calendar year (Jan 1st - Dec 31st).  Your OOP is paid at a percentage cost share between you and the insurance company.  A common percentage is 80/20, with you, the insured paying 20% until you reach your maximum OOP.

When there is more than one member covered under a plan, each member will have their own separate deductible and OOP.  An example would  be a couple who are covered under one policy, and one member was exposed to a hospital claim that satisfied his deductible and OOP.  Under this, they would receive 100% coverage the remainder of the year, but their spouse would still be subject to their own deductible and OOP.

So...you would want to multiply the plan benefits by the amount of members in your family, to get the true exposure.



-The Shoppe