UNDERSTANDING YOUR PLAN DEDUCTIBLE & OUT-OF-POCKET MAXIMUM
When you cover any family members under your medical plan, your annual deductible and out-of-pocket maximum (OOPM) may be applied differently, depending on your plan.
Aggregate Deductible / OOPM
(also collective or non-embedded)
• All covered family members work together to meet the family deductible/OOPM
• With family coverage, the individual deductible/OOPM no longer applies
• Once any combination of family members meets the family deductible, the plan’s benefits will begin to pay for all family members for the rest of the plan year
• Similarly, once any combination of family members meets the family OOPM, the plan will cover 100% of services for all family members for the rest of the plan year
Embedded Deductible / OOPM
(also non-collective or non-aggregate)
• Each covered family member meets their own individual deductible/OOPM
• Once any one family member meets the individual deductible, the plan’s benefits will begin to pay for that member
• Other family members will still have to meet their individual deductibles until the family deductible has been met; if the family deductible has been met by any combination of family members, the plan’s benefits will pay for all family members for the rest of the plan year
• Similarly, once any one family member meets the individual OOPM, the plan will cover 100% of services for that member; once the family OOPM is met my any combination of family members, the plan will cover 100% for all members for the rest of the year
EXAMPLE
• Plan deductible: $3,500 individual / $7,000 family
• The employee has a medical expense of $5,000; the family deductible is not met (even though the amount is greater than the individual deductible)
• A dependent has a medical expense of $1,250; $6,250 has been applied to the deductible so far
• Another dependent has a medical expense of $750; the deductible is now met and the plan will start paying benefits for all family members
EXAMPLE
• Plan deductible: $3,500 individual / $7,000 family
• The employee has a medical expense of $3,500; the individual deductible is met and the plan will start paying benefits for the employee only
• A dependent has a medical expense of $3,500; both their individual and the family deductible have been met
• The plan will start paying benefits for any/all additional covered dependents for the rest of the plan year
