Deductibles & Out-of-Pocket Maximums

About Your Deductibles and Out-of-Pocket Maximums

In the PPO, the deductibles and annual out-of-pocket maximums “cross apply” for in-network and out-of-network services. This means that in-network expenses count toward your out-of-network limits, and vice versa.

How do Deductibles work?

In the PPO, you must satisfy a deductible each year before the plan begins to pay certain benefits. Once an individual has met his/her individual deductible, the plan will begin to pay benefits for that individual.

If you have family coverage, you can satisfy the family deductible without each person meeting their individual deductible. See the following example.

Here’s how a family deductible works

Let’s say Jill has a family of five, elects the Basic PPO for herself and her family. She has $800 in medical expenses, her husband has $500 and two of her children have a total of $250 in covered expenses. As a family, they have $1,500 in expenses and have met the family in-network deductible of $1,500.

Only $750 of Jill’s expenses count towards the family deductible, since no more than the individual deductible amount can be applied toward the family deductible by any family member. But, because they met the family deductible amount as a group, each family member did not have to meet his or her individual deductible amount before the plan began to pay benefits for the whole family.

How do Out-of-Pocket Maximums work?

If you are enrolled in a PPO, your out-of-pocket expenses will be limited by an annual out-of-pocket maximum. If you meet the out-of-pocket maximum, the plan will pay any additional covered expenses at 100% for the rest of the calendar year. Deductibles, copays for office visits and coinsurance apply toward the out-of-pocket maximum.

Families can meet the out-of-pocket maximum without each family member meeting their individual out-of-pocket maximum. Once the family maximum is met, the plan will then pay 100% of reasonable and customary charges for the rest of the calendar year for all family members. See the example below.

Here’s how the family out-of-pocket maximum works

Jill’s out-of-pocket expenses reach $2,400, so the Basic PPO begins to pay 100% of her covered expenses. Her husband then has $2,000 and her daughter has $400 in out-of-pocket expenses. As a family, they have met the $4,800 out-of-pocket maximum. The plan will now pay 100% of covered charges for the entire family for the rest of the year, even though none of the other family members have met their out-of-pocket maximum.