The Out-of-Pocket Maximum (OOPM) amounts below are the maximum amounts you must pay for
covered services during a particular Calendar Year.
Dollar amounts set by MCOs (managed care organizations) that limit the amount a member has to pay out of his/her own pocket for particular healthcare services during a particular time period.
Once the total amount of all Copayments you pay for covered services under this Evidence of Coverage in any one Calendar Year equals “Out-of-Pocket Maximum” amount, no payment for covered services and benefits may be imposed on any Member
The OOPM amounts for this Plan (Excludes Prescription Drugs) are: Example
One Member ……………………………..$1000
Three (3) inpatient copayments per person per calendar year. – $2500
Family (three or more Members) …Not Applicable
The most you could pay during a coverage period (usually one year) for your share of the costs of covered services. After you meet this limit the plan will usually pay 100% of the allowed amount. This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges or health care your plan doesn’t cover. Some plans don’t count all of your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit.
What is the out-of-pocket limit for this plan? Example plan
For network providers $4,000
individual / $8,000 family; for outof-network
individual / $20,000 family
If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?
Premiums, balance-billing charges, and health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Will you pay less if you use a network provider?
Yes. See www.bcbswny.com or call 1-888-249-2583 for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work).
How the OOPM Works
Keep a record of your payment for covered medical services and supplies. When the total in a Calendar Year reaches the OOPM amount shown above, contact the Member Services Department at the telephone number shown on your Health Net ID Card for instructions.
• If an individual Member pays amounts for covered services in a Calendar Year that equal the OOPM amount shown above for an individual Member, no further payment is required for that Member for the remainder of the Calendar Year.
You must notify Health Net when the OOPM amount has been reached. Please keep a copy of all
receipts and canceled checks for payments for Covered Services as proof of Copayments made.
Other Party Liability (OPL)
A cost containment program that recovers money for healthcare where primary responsibility does not exist because of another group health plan or contractual exclusions. Includes coordination of benefits, Workers’ Compensation, subrogation and no-fault auto insurance
Your share (for example, 40%) of the allowed amount for covered health care services to providers who don’t contract with your health insurance or plan. Out-of-network coinsurance usually costs you more than in-network coinsurance.
A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network copayments.
Out-of-network Provider (Non-Preferred Provider)
A provider who doesn’t have a contract with your plan to provide services. If your plan covers out-of-network services, you’ll usually pay more to see an out-of-network provider than a preferred provider. Your policy will explain what those costs may be. May also be called “non-preferred” or “non-particiapting” instead of “out-of-network provider”.
Most of your Eligible Expense payment obligations are applied to the Out-of-Pocket Maximum. The Out-of-Pocket Maximum will be increased in the future in direct proportion to the increase as determined from the cost-of-living adjustments based on the Consumer Price Index (CPI-U).
The Out-of-Pocket Maximum will not include:
• Services, supplies, or charges limited or excluded by the Plan;
• Expenses not covered because a benefit maximum has been reached;
• Any Eligible Expense paid by the Primary Plan when BCBSTX is the Secondary Plan for purposes of coordination of benefits;
• Penalties for failing to obtain Preauthorization.
Individual Out-of-Pocket Maximum
When the Out-of-Pocket Maximum amount for the In-Network or Out-of-Network Benefits level for a Participant in a Calendar Year equals the “individual” “Out-of-Pocket Maximum” shown on your Schedule of Coverage for that level, the benefit percentages automatically increase to 100% for purposes of determining the benefits available for additional Eligible Expenses incurred by that Participant for the remainder of that Calendar Year for that level.
Family Out-of-Pocket Maximum
When the Out-of-Pocket Maximum amount for the In-Network or Out-of-Network Benefits level for all Participants under your coverage in a Calendar Year equals the “family” “Out-of-Pocket Maximum” shown on your Schedule of Coverage for that level, the benefit percentages automatically increase to 100% for purposes of determining the benefits available for additional Eligible Expenses incurred by all family Participants for the remainder of that Calendar Year for that level. No Participant will be required to contribute more than the individual Out-of-Pocket Maximum to the family Out-of-Pocket Maximum.
The following are exceptions to the Out-of-Pocket Maximum described above:
There are separate Out-of-Pocket Maximums for In-Network Benefits and Out-of-Network Benefits.
Eligible Expenses applied toward satisfying the “individual” and “family” Out-of-Network Out-of-Pocket Maximum will apply toward both the In-Network and Out-of-Network Out-of-Pocket Maximum amounts. However, Eligible Expenses applied toward satisfying the “individual” and “family” In-Network Out-of-Pocket Maximum amount will not apply toward satisfying the Out-of-Network Out-of Pocket Maximum amounts.
Annual Maximum Benefits (if shown on your Schedule of Coverage)
The total amount of benefits available to any one Participant for all combined categories of Eligible Expenses for a Calendar Year shall not exceed the “Annual Maximum Benefits” amount, if any, shown on your Schedule of Coverage. This Annual Maximum Benefit amount includes all payments made by BCBSTX under any benefit provision of the Plan.
At the end of a Calendar Year, a new benefit period starts for each Participant. Any unused amounts from the previous year do not accumulate. All totals from previous years do accumulate toward the Maximum Lifetime Benefits amount.
Maximum Lifetime Benefits
The total amount of benefits available to any one Participant under the Plan shall not exceed the “Maximum Lifetime Benefits” amount shown on your Schedule of Coverage.
This Maximum Lifetime Benefits amount includes all payments made by BCBSTX under any benefit provisions of the Plan including payments toward any other benefit maximums under the Plan.
Changes In Benefits
Changes to covered benefits will apply to all services provided to each Participant under the Plan. Benefits for Eligible Expenses incurred during an admission in a Hospital or Facility Other Provider that begins before the change will be those benefits in effect on the day of admission.