deductible

The APSCUF Faculty and Coaches PPO plan includes deductibles for certain types* of medical service, per the chart below.

	In-Network	Out-of-Network
Deductible	$400 per person $800 per family	$800 per person $1,600 per family
Primary Care Physician Office Visit*	$20 copay	20% after deductible
Specialist Office Visit*	$30 copay	20% after deductible
Urgent Care*	$50 copay	20% after deductible
Emergency Room	$200 copay (waived if admitted)	$200 copay (waived if admitted)
Preventive Care*	Plan pays 100% - no deductible	20% after deductible

* Deductibles do not apply to in-network preventive care or 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 Work

Single Coverage - If you incur medical services that are subject to the deductible, you will pay the first $400 of those costs. 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 $800 ($400 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 $800 for the year. This maximum deductible may be satisfied in a number of different ways:

- Two members of the family could each meet the $400 maximum for a total of $800.
- Or together as a family, they could meet the $800 maximum deductible on an aggregate basis.

For example, in a four-person family, each person could incur $200 of applicable medical services in a year, and satisfy the $800 family deductible in that manner ($200 times four people). In that example, any applicable medical services incurred by any member of the family after that point would be paid 100% by the plan*.

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.

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. Per the federal government definition, the TMOOP does not include any employee premium contributions.

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 are 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 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 does not apply.

Why is the deductible 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 the Major Medical component of the Signature 65 retiree plan), these deductibles/coinsurance have always been administered on a calendar year basis. By using a calendar year, it allows employees to maximize usage of their health care FSA election. If a member knows 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 would need to consider anticipated annual expenses from January to June and then from July to December after the deductible and coinsurance resets.