2014 Deductibles and Out-of-Pocket Maximums

What is a deductible?

A deductible is the amount you must pay before the plan begins paying for covered services and supplies. Network and non-network deductibles are entirely separate. Copayments do not count toward the deductible. The deductible is part of the out-of-pocket maximum.

What is an out-of-pocket maximum?

An out-of-pocket maximum is the most you must pay before the plan pays 100 percent of covered charges for the rest of the calendar year. Network and non-network out-of-pocket maximums are entirely separate.

Payments you are responsible for that do not apply to the medical out-of-pocket maximum include:

  • Copayments for prescriptions
  • Costs above the UCR limit

Family Deductibles and Out-of-Pocket Maximums

MCHCP “rolls up” family deductibles to ensure that spouses covered by MCHCP only have to meet one family deductible and out-of-pocket maximum. Roll-ups do not carry over from one year to the next. During Open Enrollment, each subscriber must report that he or she is married to an active state employee eligible for MCHCP benefits and provide the spouse’s Social Security number. Both must enroll in the same plan through the same carrier for this rule to apply.

PPO 300 and 600 Plans

If two or more family members are covered in a PPO plan and one family member reaches the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the individual. No more charges incurred by the individual may be used to satisfy the family deductible or out-of-pocket maximum.

If one or more additional family members meet the individual deductible or out-of-pocket maximum, the medical plan begins paying claims for the entire family.

HDHP with HSA

If two or more family members are covered in the HDHP with HSA, the family deductible or out-of-pocket maximum must be met before the medical plan begins claims payment for any family member.