The Per-person Deductible and Out-of-Pocket Maximum Provision
If you elect coverage for yourself, you must pay all deductible/out-of-pocket expenses until the per-person deductible/out-of-pocket maximum is met. After you meet the per-person deductible/out-of-pocket maximum, you will pay no further deductible/out-of-pocket 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(ren)) within a coverage level to reach the individual deductible or out-of-pocket maximum, after which the deductible or out-of-pocket maximum is satisfied for the year for that person. Covered family members who have not met the deductible or out-of-pocket maximum may then combine to meet the remainder of the deductible or out-of-pocket maximum for that coverage level. If no one person has met the individual deductible or out-of-pocket maximum, the expenses of all covered members can combine to meet the deductible or out-of-pocket maximum for that coverage level.
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Example: Amounts Applied Toward Deductibles
for In-Network Care Received in the U.S.
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On behalf of you (meets per-person deductible)
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$350
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On behalf of your spouse/domestic partner
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$250
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On behalf of one child
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$175
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On behalf of a second child
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$275
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TOTAL (meets family deductible)
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$1,050
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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 80% until your out-of-pocket maximum 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.
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Example: Amounts Applied Toward Family Out-of-Pocket Maximum
for In-Network Care Received in the U.S.
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On behalf of you (meets per-person out-of-pocket maximum)
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$1,700
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On behalf of your spouse/domestic partner
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$1,300
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On behalf of one child
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$1,150
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On behalf of a second child
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$950
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TOTAL (meets family out-of-pocket maximum)
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$5,100
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In this example, one person has met the $1,700 per-person out-of-pocket maximum (you), and the combined out-of-pocket costs after meeting the deductible, 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 out-of-pocket maximum. No other covered family members need to meet their per-person out-of-pocket maximum for the rest of the year.
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