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
|
$1,600 Deductible Plan1
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$3,200 Deductible Plan1
|
|
Out-of-pocket maximum
(including deductible)
|
In-network:
Employee: $3,200
Family2: $6,4004
Out-of-network:
Employee: $6,400
Family2: $12,8004
|
In-network:
Employee: $5,900
Family2: $11,8003
Out-of-network:
Employee: $11,800
Family2: $23,6003
|
1 These plans are named for the deductible applicable to the "individual" for in-network service providers. The deductibles applicable to any other coverage level (for example, "Family coverage") or for services provided by out-of-network service providers will be significantly higher than (in many instances, double) the amounts captured in the names of the plans.
2 "Family" applies to all coverage levels except Employee-Only.
3 Not "True" Family: For the $3,200 Deductible Plan, 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 covered family member meets his or her individual deductible, benefits begin for only that covered family member, and not for the other covered family members. When the family deductible is met, benefits begin for all covered family members whether or not each has met the individual deductible. The family deductible can only be met by a combination of covered 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 covered family member meets his or her individual out-of-pocket maximum, the out-of-pocket maximum is satisfied for only that covered family member. When the family out-of-pocket maximum is met, the out-of-pocket maximum is satisfied for all covered family members, whether or not each has met the individual out-of-pocket maximum. The family out-of-pocket maximum can only be met by a combination of covered family members, as amounts counted toward individual out-of-pocket maximums count toward the larger family out-of-pocket maximum.
4 "True" Family: For the $1,600 Deductible Plan, 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 met by one covered family member or a combination of family members. This plan does not require that you or a covered family member must meet the "individual" deductible to meet the family deductible. 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 met for any one covered family member only when the family out-of-pocket maximum is met by one covered family member or a combination of covered 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
- Expenses for non-emergency use of the emergency room
- Expenses incurred for non-urgent use of an urgent care provider
- Preauthorization 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 medical claims apply toward the out-of-network out-of-pocket maximum?
Yes. In-network claims apply toward the out-of-network out-of-pocket maximum. Also, out-of-network claims apply toward the out-of-network out-of-pocket maximum.
Do out-of-network medical 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 $1,600 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 $3,200 Deductible Plan
The Plan will begin reimbursing benefits for a covered family member (including a newborn) 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).