MMC Benefits Handbook
Out-of-Pocket Maximums
The maximum amount you have to pay toward the cost of the medical care you receive in the course of one year (excluding your per paycheck contributions to participate in the Plan). The out-of-pocket maximums vary under each of the medical plan options as follows:
Plan feature
$400 Deductible Plan
$900 Deductible Plan
$1,500 Deductible Plan
$2,850 Deductible Plan
Out-of-pocket maximum
(including deductible)
In-network:
Employee: $2,200
Family2: $4,4003
Out-of-network:
Employee: $4,400
Family2: $8,8003
In-network:
Employee: $3,000
Family2: $6,0003
Out-of-network:
Employee: $6,000
Family2: $12,0003
In-network:
Employee: $3,000
Family2: $6,0004
Out-of-network:
Employee: $6,000
Family2: $12,0004
In-network:
Employee: $5,500
Family2: $11,0003
Out-of-network:
Employee: $11,000 Family2: $22,0003
2 "Family" applies to all coverage levels except Employee-Only.
3 Not "True" Family: If more than one person in a family is covered under this plan, there are two ways the plan will begin to pay benefits for a covered family member. When a family member meets his or her individual deductible, benefits begin for that family member only, but not for the other family members. When the family deductible is met, benefits begin for every covered family member whether or not they have met their own individual deductibles. The family deductible can only be met by a combination of family members, as amounts counted toward individual deductibles count toward the larger family deductible. The out-of-pocket maximum functions in the same way. When a family member meets his or her individual out-of-pocket maximum, the out-of-pocket maximum is satisfied for that family member only, but not for the other family members. When the family out-of-pocket maximum is met, the out-of-pocket maximum is satisfied for every covered family member whether or not they have met their own individual out-of-pocket maximums. The family out-of-pocket maximum can only be met by a combination of family members, as amounts counted toward individual out-of-pocket maximums count toward the larger family out-of-pocket maximum.
4 "True" Family: This plan does not require that you or a covered eligible family member meet the "individual" deductible in order to satisfy the family deductible. If more than one person in a family is covered under this plan, benefits begin for any one covered family member only after the family deductible is satisfied. The family deductible may be met by one family member or a combination of family members. The out-of-pocket maximum functions in the same way. If more than one person in a family is covered under this plan, the out-of-pocket maximum is satisfied for any one covered family member when the family out-of-pocket maximum is satisfied. The family out-of-pocket maximum may be met by one family member or a combination of family members.
Prescription drug expenses apply toward the out-of-pocket maximum.
The out-of-pocket maximum doesn't apply to:
  • Amounts exceeding Plan limits
  • Amounts in excess of a reasonable and customary charge
  • Prior Authorization penalties
  • Services not covered by the Plan
  • Amounts exceeding the network negotiated price for prescription drugs.
Your deductible applies toward your out-of-pocket maximum.
Do in-network claims apply toward the out-of-network out-of-pocket maximum?
No. Only out-of network claims apply toward the out-of-network out-of-pocket maximum.
Do out-of-network claims apply toward the in-network out-of-pocket maximum?
Yes. Out-of-network claims apply toward the in-network out-of-pocket maximum. Also, in-network claims apply toward the in-network out-of-pocket maximum.
How does the annual out-of-pocket maximum (limit) work for family members?
Under the $400 Deductible Plan
The Plan will begin reimbursing benefits for a covered family member at 100% once he or she has met the individual out-of-pocket maximum (even if the entire family out-of-pocket maximum has not been met).
Under the $900 Deductible Plan
The Plan will begin reimbursing benefits for a covered family member at 100% once he or she has met the individual out-of-pocket maximum (even if the entire family out-of-pocket maximum has not been met).
Under the $1,500 Deductible Plan
In meeting your family out-of-pocket maximum, each family member's (including a newborn's) covered expenses (medical and prescription drug expenses) count toward the family out-of-pocket maximum.
If you cover eligible family members, you must meet the family out-of-pocket maximum. Once this out-of-pocket maximum has been met, the Plan will pay benefits for all family members at 100% for in-network providers and 100% of reasonable and customary charges for out-of-network providers.
Under the $2,850 Deductible Plan
The Plan will begin reimbursing benefits for a covered family member at 100% once he or she has met the individual out-of-pocket maximum (even if the entire family out-of-pocket maximum has not been met).