Out-of-Pocket Maximums

MMC Benefits Handbook

The maximum amount you have to pay toward the cost of the medical care you receive in the course of one year (excluding your 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 Plan4	$3,200 Deductible Plan4
Out-of-pocket maximum (including deductible)	Employee: $3,200 Family1: $6,4003	Employee: $5,900 Family1: $11,8002

1 "Family" applies to all coverage levels except, Employee-Only.

2 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.

3 "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.

4 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.

Prescription drug expenses apply toward the out-of-pocket maximum.

Your deductible applies toward your 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.

For all regions except California, 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%.

In California only, 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 of $3,200 (even if the entire family out-of-pocket maximum has not been met).

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).