When Do You Receive Out-Of-Network Benefits

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What Is the Annual Deductible
What Percentage of Covered Out-Of-Network Expenses Does the Plan Pay
What Is the Annual Out-Of-Pocket Maximum
What Is the Maximum Lifetime Benefit

With Managed Choice POS, you make the decision to use network or out-of-network providers each time you need medical care. Out-of-network benefits apply anytime you decide to use network or out-of-network providers without authorization from your PCP, except for emergency care.

If out-of-network benefits apply, you must first satisfy the annual deductible before benefits become payable. Then, the plan pays 80% of out-of-network covered expenses. You are responsible for the rest of the cost. If you reach your annual out-of-pocket maximum, the plan will pay 100% of your covered out-of-network expenses for the rest of the plan year.

Advance approval is required for hospital admissions and certain outpatient surgical and diagnostic procedures. If you do not receive advance approval, benefits will be reduced by $300. Advance approval also is required for skilled nursing facilities, home health care, and hospice care.

Out-of-network benefits have a lifetime maximum benefit of $300,000 per covered person.

If you choose to receive care that is not covered, you will be responsible for paying the full cost for the service or supply.

Benefits for psychiatric and substance abuse treatment are provided only through the separate network managed by Value Options.

What Is the Annual Deductible

The annual deductible is the amount of covered medical expenses you pay before out-of-network benefits become payable for covered medical expenses.

The annual deductible for out-of-network benefits is 1% of your annualized base pay as of July 1 for each covered person. For retirees, it is the January 1 base pay in effect the year of retirement.

The annual deductible is calculated by first rounding your annualized base pay to the nearest $1,000. For example, if your annualized base pay as of July 1 is $ 24,400, the pay is rounded to $24,000. Then 1% of the $24,000, or $240, becomes the annual deductible for each covered person in your family for the year.

For a covered family, the maximum annual out-of-network deductible is 3% of annualized base pay as of July 1. For example, if your annualized base pay as of July 1 is $ 24,000, the family maximum deductible is 3% of that amount, or $720. This means that, once you have paid $720 in covered out-of-network expenses for any combination of covered family members during the year, the plan can begin paying out-of-network benefits for all covered family members. If you have four covered family members, here's an example of how the family maximum can work based on an annualized base pay of $24,000:

Family Member One has $220 of expenses that apply toward that person's individual annual deductible.
Family Member Two has $200 of expenses that apply toward that person’s individual annual deductible.
Family Member Three has $180 of expenses that apply toward that person's individual annual deductible.
Family Member Four has $120 of expenses that apply toward that person's individual annual deductible.

Since the family has enough covered expenses to meet the family deductible of $720, no further deductibles are required for the year. In this example, the combination of covered expenses for all family members adds up to the $720 family maximum. This means each family member can begin receiving out-of-network benefits even though no one met the individual deductible of $240.

Any copayments for in-network benefits or the psychiatric and substance abuse network do not apply toward your out-of-network annual deductible. In addition, any portion of covered out-of-network expenses that is more than the usual and prevailing rate and any $300 penalty assessed for failure to obtain advance approval will not apply toward your deductible. If you move into or out of the Managed Choice POS network service area during the year, any covered expenses that apply toward your out-of-network deductible also will apply toward your out-of-area deductible and vice versa.

What Percentage of Covered Out-Of-Network Expenses Does the Plan Pay

After you pay the required annual deductibles, the plan generally pays 80% of covered expenses. Podiatric care is covered at 50%. You pay the remaining cost.

Benefits for alternate care are limited as follows:

Skilled nursing facility care up to a 180-day lifetime maximum
Home health care up to a 240-day lifetime maximum
Hospice care up to a 180-day maximum.

These maximums are a combined maximum for in-network, out-of-network, and out-of-area benefits.

For covered ambulance service, you pay $10 with no deductible. The plan pays the rest of the cost.

What Is the Annual Out-Of-Pocket Maximum

The annual out-of-pocket maximum limits the amount you pay for out-of-network covered expenses in any calendar year.

The annual out-of-pocket maximum is 3% of your annualized base pay for each covered person, with a minimum of $2,000. For a family, the out-of-pocket maximum is 6% of your annualized base pay, with a $4,000 minimum. Once the out-of-pocket maximum is reached, remaining covered expenses are paid at 100%.

The annual out-of-pocket maximum is calculated by rounding your annualized base pay to the nearest $1,000 just as with the annual deductible.

If your annualized base pay as of July 1 is $24,400, for example, the annual individual out-of-pocket maximum is 3% of $24,000 or $2,000, whichever is larger. Three percent of $24,000 is $720. In this example, then, the individual out-of-pocket maximum will be $2,000. Once the covered person's share of covered expenses, including the annual deductible, reaches $2,000 during the plan year, the plan will pay 100% of remaining covered expenses for that individual for the rest of the plan year.

The family out-of-pocket maximum is 6% of $24,000 or $4,000, whichever is larger. Since six percent of $24,000 is $1,440 the family maximum is $4,000. Once the family's out-of-pocket expenses reach $4,000, including annual deductibles, the plan will pay 100% of any remaining covered expenses for all covered family members for the rest of the plan year.

If you have four covered family members, here's an example of how the family out-of-pocket maximum can work based on an annualized base pay of $24,000:

Family Member One has covered out-of-pocket expenses, including the deductible, of $1,800 for the year.
Family Member Two has covered out-of-pocket expenses of $1,000.
Family Members Three and Four each have covered out-of-pocket expenses, including deductibles, of $600.

Once your covered out-of-pocket expenses for the family reach $4,000 for the year, the annual family out-of-pocket maximum has been met. This means the plan will pay 100% of covered expenses for the rest of the plan year for all covered family members even though no one met the individual out-of-pocket maximum.

Any copayments for in-network benefits or the psychiatric and substance abuse network do not apply toward your out-of-pocket maximum. In addition, any portion of covered out-of-network expenses that exceeds the usual and prevailing rate and any $300 penalty you are assessed for failure to obtain advance approval will not apply toward your out-of-pocket maximum. Your share of covered expenses for podiatric care also will not apply.

If you move into or out of the Managed Choice POS network service area during the year, any covered expenses that apply toward your annual out-of-network maximum also will apply toward your out-of-area maximum and vice versa.

What Is the Maximum Lifetime Benefit

The maximum lifetime benefit payable for each covered person for out-of-network benefits is $300,000.