out of pocket maximum

What What does OOP Out of Pocket Maximum, Calendar Year Deductible, co payment, co-insurance, mean in Health Insurance?

Try turning your phone sideways to see the graphs & pdf's?


How the Out of Pocket Maximum Works in Health Insurance

Video On Maximum OOP Out of Pocket

How you share costs - Deductible, Co Insurance & OOP Out of Pocket Limit

Deductible & Co Pays

#Deductible s  Calendar Year & Co Pays

Deductible – The Calendar Year amount you must pay for specific Covered Services before the plan  pays for Covered Services pursuant to this [policy] Agreement.  Sample EOC Page 107

Example from 2022 Silver 70 PPO

health insurance deductible

See evidence of coverage – Cost concepts in action 2024  Page 42

claim example in action



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News reports about how high deductibles leave people effectively without medical care as people are living on the edge – paycheck to paycheck.

#Co-Payments – Specific Covered Services 

Co Pays - Specific Services

Footnote #2 Calendar Year Deductible (CYD): 

Calendar Year Deductible explained. A Calendar Year Deductible is the amount you pay each Calendar Year before Blue Shield pays for Covered Services under the Plan.

If this Plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identified with a check mark () in the Benefits chart above.

Covered Services not subject to the Calendar Year medical Deductible. Some Covered Services received from Participating Providers are paid by Blue Shield before you meet any Calendar Year medical Deductible. These Covered Services do not have a check mark () next to them in the “CYD applies” column in the Benefits chart above.

This Plan has a separate medical Deductible and pharmacy Deductible.

This Plan has a separate Participating Provider Deductible and Non-Participating Provider Deductible.

Family coverage has an individual Deductible within the Family Deductible. This means that the Deductible will be met for an individual with Family coverage who meets the individual Deductible prior to the Family meeting the Family Deductible within a Calendar Year. Any amount you have paid toward the individual Deductible will be applied to both the individual Deductible and the Family Deductible. Once the individual Deductible or Family Deductible is reached, cost sharing applies until the Out-of-Pocket Maximum is reached.


hmo ppo & epo


Coinsurance  The percentage amount that a Member is required to pay for Covered Services after meeting any applicable Deductible.   VIDEO

Out-of-Pocket Maximum

The OOP Out of Pocket Maximum is The highest Deductible, Copayment, and Coinsurance amount an individual or Family is required to pay for designated Covered Services each year as indicated in the Summary of Benefits section.

Charges for  services that are not covered, charges in excess of the Allowable Amount or [negotiated] contracted rate do not accrue to the Calendar Year Out-of-Pocket Maximum.

out of pocket maximum

Allowable Amount – See page 105 of Specimen Policy


Notification of OOP Out of Pocket Maximum
Explanation of Benefits

Our Webpage on

How much gets #paid to an out of network provider?


How Your In-Network Health Coverage Can Vanish Before You Know It  CA Health Line  

Question? Scripps is no longer taking Medicare Advantage Plans, per their website.   If you have a Medicare Advantage Plan MAPD PPO, will the PPO pay, how much and will Scripps take it?

Answer – Scripts states they take Medicare A & B on their website. The PPO pays the same benefits as A & B, thus it looks to me like the PPO will pay and Scripps should take it.   Call to double check
800-727-4777.  I’d email them, but I don’t find an email address.  I don’t post or listen to hearsay.  If you call, PLEASE get it in writing!

PPO pays under Medicare Rules







Specimen Individual Policy #EOC with Definitions

Employer Group Sample Policy

It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc!  Plus, EOC's are mandated to be written in PLAIN ENGLISH!

Specimen Policy with Definitions

VIDEO Steve Explains how to read EOC

Videos by Steve Shorr

Insurance #definitions & glossary

Prior Authorization

Prior #Authorization

Preauthorization is A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary.  Sometimes called prior authorization, prior approval or  precertification.

Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. Health Net Glossary  * See also YOUR EOC, Evidence of Coverage!

IMHO Insurance Companies are not doctors and a lot of people and reglators agree, thus the pending laws and investigations.



Resources, Links & Bibliography

Prior Authorization in Medicare Advantage Plans: How Often Is It Used?




UCR Reasonable and customary amount

“the  UCR usual, customary, and reasonable amount,” and “the prevailing rate” are among the standards that various health care benefit plans may use to pay out-of-network benefits.  Before ACA/Obamacare and the rise of HMO’s UCR was quite common.

Please review this page more details and explanations of each of the key terms as they are interrelated.

Deductible #Carryover.

Many plans used to offer a provision called a deductible carryover.  However, Last quarter deductible carry over has gone by way of the dinosaurs – carriers no longer offer this.

This provision allows you to carry over to the next year any unmet portion of the deductible that you, or your family, run up in October, November and December. For example, assume you had no medical claims in the first part of the year. In November, you run up $350 worth of claims. If your deductible was $500, you would start the next year with $350 of your $500 deductible already meet.  Example

However, there is no deductible credit for PPO plans  since all plans are set up for Calendar Year and a renewal won’t effect this nor  a carrier change in the middle of the year since deductible credit for the yearly medical deductible is given by the new carrier (client has to submit EOBs)  9.11.2015 email from Heide Definition – Investopedia LISA Broker Wholesaler – How and what you need to do to get credit when moving from one insurance company to the other.

Benefit Period

The length of time we will cover benefits for Covered Services. For Calendar Year plans, the Benefit Period starts on January 1st and ends on December 31st. For Plan Year plans, the Benefit Period starts on your Group’s effective or renewal date and lasts for 12 months. (See your Group for details.) The “Schedule of Benefits” shows if your Plan’s Benefit Period is a Calendar Year or a Plan Year. If your coverage ends before the end of the year, then your Benefit Period also ends.  EOC   

Crediting Prior Employer Group Plan Coverage

If you were covered by the Group’s prior carrier / plan immediately before the Group signs up with us, with no break in coverage, then you will get credit for any accrued Deductible, if applicable and approved by us, under that other plan. This does not apply to people who were not covered by the prior carrier or plan on the day before the Group’s coverage with us began, or to people who join the Group later. If your Group moves from one of our plans to another (for example, changes its coverage from HMO to PPO), and you were covered by the other product immediately before enrolling in this product with no break in coverage, then you may get credit for any accrued Deductible, if applicable and approved by us. If your Group offers more than one of our products, and you change from one product to another with no break in coverage, you will get credit for any accrued Deductible, if applicable. This Section Does Not Apply To You If:

· Your Group moves to this Plan at the beginning of a Benefit Period; · You change from one of our individual policies to a group plan; · You change employers; or · You are a new Member of the Group who joins the Group after the Group’s initial enrollment with us.




What’s this about #embedded & aggregate deductibles?

Individual vs Family Deductibles?

Under family coverage, an embedded deductible is the individual deductible for each covered person, embedded in the family deductible. While it might not sound like a good thing to have two deductibles, it actually works to provide better coverage for individual members because once each family member meets his or her embedded deductible, health insurance begins paying for covered services, regardless of whether the larger family deductible is met.

Contrast this to a non-embedded deductible, also referred to as an aggregate deductible. Under an aggregate deductible, the total family deductible must be paid out-of-pocket before health insurance starts paying for the health care services incurred by any family member. While family coverage with an aggregate deductible may have a lower monthly premium, coverage won’t kick in until the total family deductible is met. In contrast, family health plans with an embedded deductible may help ensure that there is coverage for individual family members once they meet their embedded deductible, regardless of whether the family deductible is met. Unfortunately, the Summary of Benefits and Coverage won’t necessarily tell you if the deductible is embedded or not; you may have to call the plan to learn how the deductible will be applied for your coverage.   Learn More⇒ Center on Health Insurance Reforms   AB 1305

If two or more on a policy it’s the Family Deductible NOT individual, with a family max?

See excerpt of Blue Cross Bronze HSA Page 55 on Family or Individual Deductible

NEW for 2016!!!  Embedded – HSA plans had an aggregate deductible where one person could meet the entire family deductible.   Now a family member will not be charge more than the individual deductible and be able to receive benefits sooner.  BC RSM Email 9.29.2015    SHRM.org   AB 1305 2015 Bonta

2017 NEW Laws & Regulations effective 1.1.2017  AB 1305, 339 & 1954  SB 999 – Deductible & OOP Maximums FAQ’s

What is the Maximum that can be contributed to an HSA – Health Savings Account?

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