The Per-Person Deductible and Coinsurance Maximum Provision

The prior sections describe the deductible and coinsurance maximums — outlining services that are and are not subject to the deductible, as well as the portion the Plan pays in coinsurance and coinsurance maximums established within the Medical Plan.

If you have elected Employee Only coverage, then the deductible and coinsurance descriptions and amounts shown in the chart will apply.

If you cover dependents, the charts under "The Annual Deductible" and "The Annual Coinsurance Maximum" depict the deductible level and coinsurance maximum levels that apply for that coverage level (i.e., employee plus adult, or family coverage).However, there is also a "per person" rule that allows any single individual (for example, the employee or a covered spouse/domestic partner or child) within a coverage level to reach the individual deductible or coinsurance maximum, after which the deductible or coinsurance maximum is satisfied for the year for that individual.

Covered family members who have not met the deductible or coinsurance maximum may then combine to meet the remainder of the deductible or coinsurance maximum for that coverage level. If no one individual has met the individual deductible or coinsurance maximum, the expenses of all covered members can combine to meet the deductible or coinsurance maximum for that coverage level.


An Example: Amounts Applied Toward In-Network Family Coinsurance Maximum for Medical Plan Option 1 After Deductibles Were Met (Total Annual Cash Compensation < $60,000)
On behalf of you	$1,000
On behalf of your spouse/domestic partner	$100
On behalf of one child	$50
On behalf of a second child	$50
TOTAL	$1,200
In this example, one person has met the $1,000 per-person coinsurance maximum (the employee), and combined coinsurance costs for the family have reached $1,200. Any charges for eligible medically necessary covered services for the employee's care would therefore be reimbursable at 100% for the remainder of the year, even though the family as a whole has not yet met the family coinsurance maximum for the Total Annual Cash Compensation < $60,000 tier ($2,000).

Note: If your coverage level changes during a calendar year as a result of Qualified Status Change, your annual deductible and/or annual coinsurance maximum increases or decreases accordingly. For example, your deductible will go back to the individual amount if you move from Employee + spouse/domestic partner or Employee + child(ren) to Employee only during the year as a result of a Qualified Status Change.