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How the Out of Pocket Maximum Works in Health Insurance
- Graph Source Health Net Glossary Page 6
- Get quotes, subsidies, net premium, deductibles, co-pays, OOP Out of Pocket maximum from all Individual companies * Employer Group
- Provider Finder See also our Site Map for instructions & details on each companies provider finder
- Glossaries – Dictionaries
Calendar Year Deductible
- Copayment The specific dollar amount that a Member is required to pay for Covered Services after meeting any applicable Deductible.
- Learn more Co Pays
- Coinsurance The percentage amount that a Member is required to pay for Covered Services after meeting any applicable Deductible.
- Learn more Co-insurance
- Out-of-Pocket Maximum OOP 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 contracted rate do not accrue to the Calendar Year Out-of-Pocket Maximum. Sample EOC Page 107
- Definitions Health Insurance Terms VIDEO
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.
Coinsurance The percentage amount that a Member is required to pay for Covered Services after meeting any applicable Deductible. VIDEO
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.
Allowable Amount – See page 105 of Specimen 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!
- Find your own Individual EOC Evidence of Coverage
- It' important to use YOUR EOC not just stuff in general!
- Obligation to READ your EOC
- Employer Group Plans
- Medi-Cal HMO – Managed Care Providers
- Our Webpage on Evidence of Coverage
- Plain Meaning Rule - Plain Writing Act
- Our Webpage on OOP Out of Pocket Maximum - Many definitions are explained there.
- The best place to look for Insurance definitions & glossary is in an actual EOC – Evidence of Coverage (specimen – Platinum) – Policy. Be sure to check your ACTUAL EOC for your specific question.
- See our definitions, video’s, guides, etc. below and on the sides.
- Numerous other Medical, Legal & Insurance Dictionaries
- CA Dept of Insurance Glossary
- CMS – Medicare
- Medicare Part D Rx Guide Definitions # 11109
- AB 1083 Definitions – Small Employer Health Care Reform Legal Dictionary Lectlaw Medicare Glossary
- Health Net 6 page glossary
- Español (Spanish)
- Court Site
- Legal Dictionary Lectlaw
- Medi-Cal – Helpful words to know
- Department of Labor – Health Benefits Advisor *** Glossary
- Texas DOI Glossary
- Glossary of Employee Benefit Terms
- State of CA Insurance Dept.
- CA DOI – Health Insurance Terms
- Glossary from Sales Brochure
- Forbes - Too many consumers don't know the terms
- Our webpage on OOP, more definitions and examples
- Prior Authorization - Regulatory Investigation aka “preauthorization” and “precertification” KFF.org 5.20.2022
- AMA: Insurers not sticking to prior authorizations deal from 2018 Modern Health Care 5.24.2022
Notification of OOP Out of Pocket Maximum
Explanation of Benefits
- SB 368, requires most state-regulated private-sector health plans to send enrollees updates, an EOB Explanation of Benefits for every month in which they received care, showing how much they have paid toward their annual deductible — the amount a person must shell out before insurance begins to cover most of their care — and how close they are to reaching out-of-pocket limits, the amount after which the insurer pays for 100% of care. CA Health Line.org *
Our Webpage on
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.
Ask Us a Question
News reports about how high deductibles leave people effectively without medical care as people are living on the edge – paycheck to paycheck.
- Los Angeles Times May 2, 2019 * May 2 3 Kids $15k Medical Debt *
- NPR May 3, 2019
- New York Magazine.com 5.3.2019
- North County Public Radio 5.3.2019
- How to figure out the Family Deductible & OOP? Insure Me Kevin.com
- Soaring insurance deductibles and high drug prices hit sick Americans with a ‘double whammy’ LA Times
- Learn about Embedded vs aggregate deductible
- How might an HSA Health Savings Account help you save up to pay the deductible?
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 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.
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 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.
ACA Obamacare Essential (Mandatory) Benefits
- (A) Ambulatory patient services.
- (B) Emergency services.
- Emergency response ambulance or ambulance transport services
- (C) Hospitalization.
- (D) Maternity [but not infertility - CA Law? ] and newborn care.
- §146.130 Standards relating to benefits for mothers and newborns.
- Maternity: Inpatient hospital and ambulatory
- Prescription drug coverage for contraceptives
- Maternity hospital stay
- Sterilization operations and procedures View the Affordable health ca.com page Assembly Bill 1453 (Monning) and Senate Bill 951 (Hernandez). View the California Health and Safety Code, section 1367.005
- Abortion G-d forbid
- (E) Mental health and substance use disorder services, including behavioral health treatment.
- (F) Prescription drugs. CFR 156.122
- (G) Rehabilitative and habilitative [learn or improve skills for daily living] services and devices.
- (H) Laboratory services.
- (I) Preventive and wellness services and chronic disease management.
- Diabetes education, management and treatment
- (J) Pediatric services, including Dental - oral and vision care. Blue Shield Individual Flyer Essential Health Benefits 5.2013 Group Essential Health Benefits (EBH) 42 USC 18022 SB 951
- (H?) Cancer and other life threatening disease - clinical trials
- AIDS vaccine
- HIV testing
- Organ transplants for HIV
- Alpha feto protein testing
- Prosthetics for laryngectomy
- Reconstructive surgery
- Mastectomies and lymph node dissections
- Cervical cancer treatment
- Osteoporosis treatment
- Surgical procedures for jaw bones
- Anesthesia for dental
- Conditions attributable to diethylstilbestrol
- Hospice (end of life) care
- Pain management medication for terminally ill
- Phenylketonuria treatment
- § 1300.67.005. Essential Health Benefits Westlaw Barclays California Code of Regulations
- California Benchmarks Kaiser Small Group HMO 30 ♦ CA SB 43 effective 1.1.2016 makes this the benchmark for individual plans too.
- VIDEO from Blue Cross North Carolina
- Health Care.Gov
- CMS.gov very detailed
- CHCF Comparison of CA vs Federal Rules as of 2014
- Frequently Asked Questions on Essential Health Benefits Bulletin from the Department of Health and Human Services (PDF)
- Essential Health Benefits Bulletin from the Department of Health and Human Services, Dec. 16, 2011 (PDF)
No more Annual & Lifetime Limits under Health Care Reform Aetna's Explanation
White House.Gov Affordable Health Care Act YouTube Channel
- Here's the Feb. 20, 2013 final.rule establishing the essential health benefits (EHBs) for 10 categories of care, including basic services such as hospitalization and emergency care, as well as mental health and maternity care. In addition, the plans must cover a minimum of 60 percent of the actuarial value of covered medical services.
- Our main webpage on California & Federal Essential Health Benefits