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The out-of-pocket limit is the most you pay in a calendar year for covered services from preferred providers. Once you meet this limit for the year, the plan pays covered services by preferred providers at 100 percent of the allowed amount.
Expenses are counted from January 1, 2017, or your first day of enrollment (whichever is later), to December 31, 2017, or your last day of enrollment (whichever is first).
Effective in 2016: An individual cannot exceed $6,850 in covered out-of-pocket expenses annually.
Number of persons covered
Limit per calendar year
One person covered
Two or more covered
Once an individual meets $6,850 in covered out-of-pocket expenses annually, the plan will pay for covered services at 100 percent for that individual.
- Your coinsurance paid to preferred and participating providers.
- Your deductible.
- Your out-of-pocket costs for covered prescription drugs and products.
- Amounts paid by the plan, including services covered in full (preventive).
- Non-network pharmacy charges that exceed the allowed amount.
- Balance billed amounts. For exceptions, see “Exceptions: Out-of-network provider services that count” below.
- Services not covered by the plan.
- Amounts more than a maximum dollar amount paid by the plan. For example, the plan pays a maximum of $150 for adult vision hardware once every two calendar years. Any amount you pay over $150 does not count toward the out-of-pocket limit.
- Amounts paid for services exceeding a benefit limit. For example, the benefit limit for acupuncture is 16 visits. If you have more than 16 acupuncture visits in one year, you will pay in full for those visits and what you pay will not count toward this limit.
Note: You will still be responsible for paying numbers 2–6 above after you meet your out-of-pocket limit.
Services by out-of-network providers are paid by the plan at 60 percent of the allowed amount (see below for exceptions). Even after you meet your out-of-pocket limit, you will pay 40 percent coinsurance for out-of-network provider services and the provider may still balance bill you. Balance billed amounts do not count toward your out-of-pocket limit.
Exceptions: out-of-network provider services that count
In certain cases, your coinsurance and balance billed amounts for out-of-network provider services will count toward your out-of-pocket limit. In addition, the plan will pay 100 percent of billed charges for these services after you meet your out-of-pocket limit.
- Services for which you have an approved network waiver.
- Cochlear Implant Processor Supplier.
- Ocularists (creation and fitting of prosthetic eyes)
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