Deductibles and Coinsurance

The Nonrepresented, OPEIU, SPFPA, and POA PPO plan includes deductibles and coinsurance for certain types* of medical services, per the chart below.

	In-Network	Out-of-Network
Deductible	$250 per person $500 per family	$500 per person $1,000 per family
Member Coinsurance	10%	30%
Out-of-Pocket Maximum (coinsurance)	$1,000 per person $2,000 per family	$2,000 per person $4,000 per family
Primary Care Physician Office Visit*	$15 copay	30% after deductible
Specialist Office Visit*	$25 copay	30% after deductible
Urgent Care*	$25 copay	30% after deductible
Emergency Room	$100 copay (waived if admitted)	$100 copay (waived if admitted)
Preventive Care*	Plan Pays 100% - no deductible	30% after deductible

*Deductibles and coinsurance do not apply to in-network preventive care or to services for which a copay applies.

Preventive Care

There are no member costs for preventive care at in-network providers–the plan pays 100% of the costs for qualifying preventive services. By following the recommendations in the preventive schedule, you may be able to either prevent certain medical conditions, or detect them before they become more serious.

If your medical provider orders diagnostic tests/screenings that are not covered on the preventive schedule, those services may be subject to additional costs (e.g. Deductible and/or coinsurance)

Balance Billing

If you use an out-of-network provider, you may be subject to balance billing - the provider can bill the difference between the insurance allowance and their full charge, which can be significant.

How Deductibles and Coinsurance Work

Single Coverage - If you incur medical services that are subject to the deductible, you will pay the first $250 of those costs, and then 10% of the subsequent costs, up to an annual maximum of $1,000 in coinsurance payments. In total, your expenses for these types of services are capped at $1,250 for the year ($250 in deductible + $1,000 in coinsurance). All remaining costs for these applicable services for the calendar year will be paid 100% by the plan.*

Two Party Coverage - Your maximum annual deductible would be $500 ($250 for each person) and then 10% of the subsequent costs up to your annual maximum coinsurance of $2,000 ($1,000 maximum for each person). Then, all remaining costs for these types of services for the calendar year would be paid 100% by the plan.*

Multi-Party Coverage - Your maximum deductible for your family is $500 for the year. This maximum deductible may be satisfied in a number of different ways:

- Two members of the family could each meet the $250 maximum for a total of $500.
- Or together as a family, they could meet the $500 maximum deductible on an aggregate basis.

For example, in a four-person family, each person could incur $125 of applicable medical services in a year, and satisfy the $500 family deductible in that manner ($125 times four people). In that example, any applicable medical services incurred by any member of the family after that point would be subject to the 10% coinsurance payments (with the remaining 90% of costs paid by the plan).

The 10% coinsurance annual out-of-pocket family maximum of $2,000 works in the same manner–it could be satisfied individually by two members of the family, or on an aggregate basis by three or more family members. No one person in the family will ever pay more than $250 in deductible, or more than $1,000 in coinsurance payments

Examples assume all medical services are incurred in-network.
*Members may incur other medical costs in the form of office visit and prescription drug copays.

Frequently Asked Questions

What is the Total Maximum Out-of-Pocket (TMOOP) that I saw on the PPO Benefit Summary?

This is mandated by the federal government to limit the amount of out-of-pocket expense a member may experience by using in-network providers in a calendar year. This amount includes all copays and in-network deductibles/coinsurance a member has paid for medical services and prescription drugs in a calendar year. The dollar value of the TMOOP may be adjusted annually by the federal government.

How is Total Maximum Out-of-Pocket (TMOOP) different from the Out-of-Pocket Maximum?

The total maximum out-of-pocket includes all medical and prescription out-of-pocket expenses including copays and in-network deductibles/coinsurance in a calendar year. The out-of-pocket maximum includes only member coinsurance in a calendar year.

Do copays apply to the deductible?

Copays do not apply to the deductible or coinsurance.

Does the deductible and coinsurance apply to preventive care services?

No. Preventive care services at an in-network provider is provided at no member cost. The plan pays 100% with no deductible or coinsurance applying. Please refer to the preventive schedule for the PPO plan by clicking here. In order for Highmark to know the claim is preventive, the provider must submit the claim as preventive.

Is the bi-weekly employee premium contribution included in the Total Maximum Out-of-Pocket (TMOOP)?

No. TMOOP is mandated by the federal government to limit the amount of out-of-pocket expense a member may experience by using in-network providers in a calendar year. This amount includes all copays and in-network deductibles/coinsurance a member has paid for medical services and prescription drugs in a calendar year. The dollar value of the TMOOP may be adjusted annually by the federal government.

Is there a deductible carryover option on this plan?

(Some plans state that if you meet the deductible in the last quarter of the plan year they will apply the deductible to the new calendar year.) With the advent of health care reform and the total maximum out of pocket requirement, it has become administratively burdensome for insurance companies to accurately process carryover deductibles. In order to minimize claim errors, the carryover provision no longer applies.

Why is the deductible/coinsurance on a calendar year basis instead of a fiscal year basis?

For many employers, deductibles and coinsurance are on a calendar year instead of their fiscal year. For the State System plans which have incorporated an annual deductible and/or coinsurance (for example PPO out-of-network services and and the Major Medical component of the Signature 65 retiree plan), these deductibles/coinsurance have always been administered on an annual basis. By using a calendar year, it allows employees to maximize usage of their health care FSA election. If a member knows that the maximum that could be paid out-of-pocket (other than copays) then the member can use that information to make an informed election in the health care FSA. If the deductibles and coinsurance were reset each July, a member would have a more difficult time trying to determine the right amount for a health care FSA. A member will need to consider anticipated annual expenses from January to June and then from July to December after the deductible and coinsurance resets.