The Per-person Deductible and Coinsurance Maximum Provision

If you elect coverage for yourself, you must pay all deductible/coinsurance expenses until the per-person deductible/coinsurance maximum is met. After you meet the per-person deductible/coinsurance maximum, you will pay no further deductible/coinsurance expenses for the year.

If you cover dependents, the "per person" rule allows any single person (e.g., 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 person. 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 person 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.


Example: Amounts Applied Toward Deductibles for In-Network Care Received in the U.S.
On behalf of you (meets per-person deductible)	$350
On behalf of your spouse/domestic partner	$250
On behalf of one child	$175
On behalf of a second child	$275
TOTAL (meets family deductible)	$1,050
In this example, you have met the $350 per-person deductible, and the combined costs for you and all of your dependents have satisfied the family deductible ($1,050). So any additional reasonable and customary (R&C) charges for medically necessary covered services would be reimbursable at 60% until your coinsurance limit is met, even if they were on behalf of a person who has not yet met the $350 per-person deductible. No other covered family members need to meet their per-person deductible for the rest of the year.


Example: Amounts Applied Toward Family Coinsurance Maximum for In-Network Care Received in the U.S.
On behalf of you (meets per-person coinsurance maximum)	$1,700
On behalf of your spouse/domestic partner	$1,300
On behalf of one child	$1,150
On behalf of a second child	$950
TOTAL (meets family coinsurance maximum)	$5,100
In this example, one person has met the $1,700 per-person coinsurance maximum (you), and the combined coinsurance costs have reached $5,100. So, any additional reasonable and customary (R&C) charges for medically necessary covered services would be reimbursable at 100% for the remainder of the year, even if they were on behalf of a person who has not yet met the per-person coinsurance maximum. No other covered family members need to meet their per-person coinsurance maximum for the rest of the year.