Embedded Family Deductibles

Family plans have both individual deductibles, which apply to each person, and a family deductible, which applies to all family members.

Note: Learn more about cost-sharing in Copays, Deductibles, Coinsurance, and Out of Pocket Max (OOPM).

An embedded deductible is a system that combines individual and family deductibles in a family health insurance policy. Each person has their own deductible, but the family also has a maximum total deductible if multiple family members need medical care during the year.

Under a family plan, post-deductible benefits apply:

• Once a family meets their individual deductible or
• After two or more enrollees meet the cumulative family deductible

Embedded Cost-Sharing Example

Consider an E35 plan that covers a family of 4, e.g., Employee + Spouse + 2 Children, with the following deductibles and OOPMs (E plans = 30% coinsurance):

• $4,000 individual deductible
  • If a member meets the $4,000 individual deductible, the member will pay 30% of services until OOPM is reached for that member.
• $7,500 individual out-of-pocket max (OOPM)
  • If a member meets their $7,500 individual OOPM, the plan will pay 100% of services until the end of the policy year for that member.
• $8,000 family deductible
  • If 2+ members meet the $8,000 family deductible (cumulatively), all members will pay 30% of services until OOPM is reached for all members. 
• $15,000 family out-of-pocket max (OOPM)

If two or more members meet the $15,000 family deductible (cumulatively), the plan will pay 100% until the end of the policy year for all members.