The deductible is the amount that members must pay before post-deductible benefits kick in. The out-of-pocket maximum (OOPM) is the amount that members must pay before post-OOPM benefits kick in.
*To find what care costs are subject to your deductible & OOPM, refer to the Summary of Benefits and Coverages (SBC) and/or Summary Plan Description (SPD) in your Documents center.
Post-deductible benefits refers to the coinsurance benefits that activate once a member reaches the plan deductible. Coinsurance amounts are determined by the plan a member is enrolled in; see Copays, Deductibles, Coinsurance, and Out of Pocket Max
*To view your deductible and OOPM progress, log in to your Sana Portal and refer to the Medical Spend section on My Dashboard
Family plans have both individual deductibles & OOPMs, which apply to each person, and a family deductible & OOPM, which apply to all family members, i.e. Embedded Deductibles and OOPMs.
Under a family plan, post-deductible benefits kick in for an individual once that person meets their individual deductible, or once 2+ enrollees meet the family deductible (cumulatively). This means that a member on a family plan can enjoy post-deductible benefits once 2+ members meet the family deductible (cumulatively), even if that member hasn't met their individual deductible. This applies post-OOPM benefits as well.
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 2+ members meet the $15,000 family deductible (cumulatively), the plan will pay 100% until the end of the policy year for all members.
- If 2+ members meet the $15,000 family deductible (cumulatively), the plan will pay 100% until the end of the policy year for all members.
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