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Deductible and Out-of Pocket-Maximum How they work on CareFirst plans

Deductible

The amount of money a member must pay for healthcare services each year before the insurance company begins to pay its portion.  

CareFirst  Premier deductible

  • Medical and pharmacy deductible and Out-of-Pocket maximum are separate under this plan.
  • Members may have to meet their deductible and then have a copayment or coinsurance depending upon the services.   All deductible expenses, coinsurance, and copayments count towards the out-of-pocket maximum. The amount depends upon the services rendered.

 

Individual plan participant only pays the individual deductible amount before they receive benefits. 

  • Medical In-Network ($1,000): An individual plan participant medical deductible is $1,000.
  • Pharmacy In-Network ($0): An individual plan participant prescription deductible is $0.
  • Medical Out-of-Network ($2,000): An individual plan participant deductible is $2,000.
  • Note: The in-network medical deductible counts toward the out-of-network deductible. 
  • Medical In-Network: $2,000 family deductible 
  • Pharmacy In-Network: $0 family deductible
  • Each family member cannot contribute more than the $1,000 individual medical deductible.
  • If one family member meets the $1,000 individual medical deductible, that family member can start receiving benefits. 
  • The $2,000 family medical deductible must be met before any remaining family members can start receiving benefits.   
  • Medical In-Network ($2,000): Each person in Employee + Child, + Spouse, + Family can only contribute $1,000 towards the in-network deductible up to the $2,000 family deductible.   
    • Medical example: A family of four enrolls in this plan – this example demonstrates how expenses are applied towards the deductible.  
      • Family Member #1 has $1,000 in medical expenses in January. Member has satisfied their $1,000 individual in-network medical deductible in January. 
      • Family Member #2 has $600 in medical expenses in February which counts towards their own $1,000 individual in-network medical deductible.  
      • Family Member #3 has $400 in medical expenses in March.  At this point, the family has satisfied their $2,000 in-network family medical deductible. 
      • Family Member #4 has $500 in medical expenses in April.  Because the family has satisfied their $2,000 in-network family medical deductible, the $500 of medical expenses will be subject to the plans benefits (copays, coinsurance, etc.)  
  • Medical Out-of-Network: $4,000 deductible. 

CareFirst Savings Bundle deductible

  • In this plan the medical and prescription deductibles are integrated, and both apply towards the combined out-of-pocket maximums for both in-network and out-of-network.
    • Covered prescriptions count towards the deductible and are applied towards the medical plan out-of-pocket maximum in the CareFirst Savings Bundle.  
  • Coinsurance counts towards the in-network and out of network out-of-pocket maximum.
  • Combined Medical and Pharmacy In-Network ($3,000): An individual plan participant’s deductible is $3,000.  
  • Combined Medical and Pharmacy Out-of-Network ($6,000): An individual plan participant’s deductible is $6,000. 
  • The in-network deductible counts towards the out-of-network deductible. 
  • Combined Medical and Pharmacy In-Network ($6,000): The family deductible can be met by one family member or any combination of family members’ medical and prescription expenses. 
    • Example: A family of four enrolls in this plan – this example demonstrates how expenses are applied towards the deductible. 
      • Family Member #1 has $5,000 in medical and prescription expenses in January; all these expenses go towards the deductible. $5,000 of the $6,000 deductible has been met. 
      • Family Member #2 has $250 in medical and prescription expenses in February; all these expenses go towards the deductible. $5,250 of the $6000 deductible has been met at this point. 
      • Family Member #3 has $250 in medical and prescription expenses in March; all these expenses go towards the deductible. $5,500 of the $6,000 deductible has been met. 
      • Family Member #4 has $500 in medical and prescription expenses in April; all these expenses go towards the deductible. $6,000 of the $6,000 deductible has been met. Beyond this point, all of the family’s medical and pharmacy services will be subject to the plan's benefits (coinsurance, etc.). 
  • Combined Medical and Pharmacy Out-of-Network ($12,000); however, remember, pharmacy services are not covered at out-of-network pharmacies.

Out-of-Pocket Maximum

The maximum amount a member will pay out-of-pocket in coinsurance, copays and/or deductibles in a plan year for covered healthcare services. Once the out-of-pocket maximum is met, the plan pays 100% of the allowed amount for covered services for the rest of the benefit period. 

CareFirst Premier Out-of-Pocket Maximum

  • Individual plan (Medical = $4,000 and Prescription = $4,000; reminder, the medical and pharmacy out-of-pocket maximum are separate under this plan).
  • Individual plan participant only pays the individual out-of-pocket maximum amount before services are covered at 100% up to the allowable amount.
  • Medical In-Network ($4,000): An individual plan participant out-of-pocket maximum is $4,000 
    • In-Network: Once the plan participant meets the $4,000 out-of-pocket maximum the plan pays 100% up to the allowable amount ($1,000 deductible and then another $3,000). 
  • Pharmacy In-Network ($4,000): An individual plan participant out-of-pocket maximum is $4,000.
  • Medical Out-of-Network ($6,000): Once the plan participant meets the $6,000 out-of-pocket maximum the plan pays 100% up to the allowable amount ($2,000 deductible and then another $4,000).
  • Note: (1) the medical in-network out-of-pocket maximum counts toward the medical out-of-network out-of-pocket maximum and (2) the medical and pharmacy out-of-pocket maximum are separate under this plan 
  • Each family member cannot contribute more than the $4,000 Medical individual out-of-pocket maximum amount plus the $4,000 prescription individual out-of-pocket maximum.  
  • When one family member meets the $4,000 individual medical out-of-pocket maximum, that family member's medical services will be covered at 100% up to the allowed benefit. The same applies to the separate $4,000 individual pharmacy out-of-pocket maximum. 
  • The family medical out-of-pocket maximum must be met before the medical services for all remaining family members will be covered at 100% up to the allowed benefit. The same applies to the separate family pharmacy out-of-pocket maximum. 
  • Medical In-Network: ($8,000)  
    • Medical Example: A family of four enrolls in this plan – this example demonstrates how expenses are applied towards the in-network out-of-pocket maximum.  
      • Family Member #1 has $100,000 in medical expenses in January; this member has satisfied both their $1,000 individual in-network medical deductible and their $4,000 individual in-network out-of- pocket maximum and now has services covered at 100% up to the allowable amount for that individual, and the $4,000 also counts towards the $8,000 out-of- pocket maximum. 
      • Family Member #2 has $600 in medical expenses in February which counts towards both their individual $1,000 individual in-network medical deductible and their $4,000 individual out-of- pocket maximum. 
      • Family Member #3 has $400 in medical expenses in March.  At this point, the family has satisfied their $2,000 in-network family medical deductible.  These expenses also count towards their $4,000 individual out-of- pocket maximum and the family’s $8,000 out-of- pocket maximum. 
      • Family Member #4 has $1,000 in medical expenses, which are subject to 20% coinsurance in April.  Family Member #4 pays $200 for the services. At this point, because the family has met their in-network family deductible, and the family has not yet reached the $8,000 family in-network medical out-of- pocket maximum, the total expenses for the family are $5,200, below the $8,000: 
        • #1: $4,000 
        • #2: $600 
        • #3: $400 
        • #4: $200 
      • Family Member #4 has an additional $100,000 in medical expenses, which are subject to 20% coinsurance in May.  Family Member #4 pays $2,800 for the services in order for the family to reach the $8,000 family in-network medical out-of-pocket maximum.  After this point, the medical services for all remaining family members will be covered at 100% up to the allowed benefit. 
  • Medical Out-of-Network: $12,000 out-of-pocket maximum. 

CareFirst Savings Bundle Out-of-Pocket Maximum

  • Combined Medical and Pharmacy In-Network: An individual plan participant out-of-pocket maximum is $7,000 ($3,000 from the deductible and then another $4,000).
  • Combined Medical and Pharmacy Out-of-Network: An individual participant out-of-pocket maximum is $12,000 ($6,000 from the deductible and then another $6,000).
  • The combined medical and pharmacy family in-network out-of-pocket maximum ($14,000) must be met before the services for all family members will be covered at 100% up to the allowed benefit.
  • Each family member cannot contribute more than the individual out-of-pocket maximum amount of $7,000 (which includes what they paid towards the $6,000 integrated deductible). 
  • When one family member meets the individual medical and pharmacy out-of-pocket maximum ($7,000), that family member's services will be covered at 100% up to the allowed benefit.  
  • Combined Medical and Pharmacy In-Network ($14,000): Each person on the plan can only contribute $7,000 towards the $14,000 family out-of-pocket maximum.  
    • Example: A family of four enrolls in this plan – this example demonstrates how expenses are applied towards the Out-of-pocket Maximum  
      • Family Member #1 has $100,000 in medical and prescription expenses in January; this member has satisfied both their $6,000 family in-network deductible and their $7,000 individual in-network out-of-pocket maximum, and the individual will now have services covered at 100% up to the allowable amount. 
      • Family Member #2 has $1,000 in medical and prescription expenses in February.  Because the family in-network deductible has been met, these expenses are subject to plan benefits, 20% coinsurance for this example, and the member pays $200.  This $200 counts towards this individual’s own $7,000 in-network out-of-pocket maximum and the $14,000 family in-network out-of-pocket maximum. 
      • Family Member #3 has $100,000 in medical and prescription expenses in March.  After applying plan benefits (coinsurance) these expenses result in the family satisfying their family $14,000 in-network out-of-pocket maximum, and the family will now have services covered at 100% up to the allowable amount: 
        • #1: $7,000 
        • #2: $200 
        • #3: $6,800 
  • Out-of-Network: $24,000 out-of-pocket maximum.