Some health plans have annual deductibles and annual out-of-pocket maximums. It’s important to understand how these features work when choosing and using your health plan benefits. In addition to the details below, keep the following in mind:
- In plans that include coverage for in-network and out-of-network providers, out-of-network charges do not count toward your in-network deductible and out-of-pocket maximum.
- Similarly, in-network charges do not count toward your out-of-network deductible and out-of-pocket maximum.
- Your paycheck contributions to purchase health care coverage do not apply toward any plan deductibles or out-of-pocket maximum.
How the Deductible Works
When you access health care, the deductible is what you pay out of your own pocket before your insurance begins to pay a share of your costs. If you are in a plan with a deductible, you pay the full negotiated costs of all services until you reach the annual deductible amount. The negotiated costs are the payments doctors, hospitals and other providers have agreed to accept for a particular service from the insurance carrier.
If you are enrolled in individual coverage, the deductible is met when you reach the individual deductible amount. If you are enrolled in coverage with one or more other family members, the way the deductible works depends on the type of plan you choose:
- Traditional deductible in Bronze, Gold and Platinum plans: If you choose a Bronze, Gold or Platinum medical plan, you have a traditional deductible. Once a covered family member meets the individual deductible amount, your insurance begins paying benefits for that family member. Charges for all other covered family members continue to count toward the family deductible. Once the family deductible is met, your insurance pays benefits for all covered family members.
- True family deductible in Bronze Plus and Silver plans: If you choose a Bronze Plus or Silver plan, you have a true family deductible, and there is no individual deductible when the employee and more than one family member are covered in the plan. The entire family deductible must be met before your insurance will pay benefits for any covered family members. So even if one person in your family has a lot of expenses, you’ll have to pay for it on your own until the full family deductible is met.
How the Out-of-Pocket Maximum Works
The out-of-pocket maximum is the most you have to pay for covered medical services in a year. Generally, it includes any applicable deductible, copayments and/or coinsurance.
If you are enrolled in individual coverage, the out-of-pocket maximum is met when you reach the individual out-of-pocket maximum amount. If you are enrolled in coverage with one or more other family members, the way the out-of-pocket maximum works depends on the type of plan you choose:
- Traditional out-of-pocket-maximum in Bronze, Gold and Platinum plans: Once a covered family member meets the individual out-of-pocket maximum, your insurance pays the full cost of covered charges for that family member. Charges for all covered family members continue to count toward the family out-of-pocket maximum. Once the family out-of-pocket maximum is met, your insurance pays the full cost of covered charges for all covered family members. (If you choose coverage under Kaiser Permanente, copays for certain medical benefits may not apply towards the annual out-of-pocket maximum in the Gold and Platinum options.)
- True family out-of-pocket-maximum in Bronze Plus and Silver plans. The entire family out-of-pocket maximum must be met before your insurance pays the full cost of covered charges for any covered family member. There is no individual out-of-pocket maximum when you have coverage that includes yourself and one or more other family members.
If you have any questions about deductibles or out-of-pocket maximums, contact your insurance carrier or the DXC Benefits Center.