Sharing the Cost

Here’s how the deductible works:

  • The HealthFund* helps meet your deductible by paying covered expenses first.
  • When the HealthFund pays an expense, your deductible is reduced by the amount of the expense.
  • If the HealthFund is depleted before the deductible is met, you pay expenses out of your own pocket until it’s met. This is also true if there’s a zero balance in your HealthFund at the time you incur the expense.
  • If you are enrolled as a family (employee + 2 or more), each covered family member must meet his or her individual deductible — up to the family deductible limit — before the plan pays benefits.
  • After the deductible is met, you and the plan share in the cost of your care. You pay a percentage of your expense (called coinsurance).
  • The plan puts a limit on what you must pay in coinsurance each year. This is called the out-of-pocket maximum. Once you reach this maximum, the plan pays 100% of your covered expenses for the rest of the year.
  • If you are enrolled as a family, each family member must meet his or her individual out-of-pocket maximum — up to the family limit — before the plan pays benefits at 100% for the rest of the year.

Beginning January 1, 2015, prescription drugs have their own out-of-pocket maximum.

Look it up:  The Benefits Summary shows the plan’s deductible, coinsurance and out-of-pocket maximum amounts.

See how this works.
Example of Catastrophic Claim

How costs are shared.
Coverage: Employee
Cost of care: $50,000
Provider: In-network
HealthFund balance: $250

Plan feature What LMC Pays
(percentage)
What you pay
(percentage)
What you pay
(dollar amount)
Annual deductible
(first $1,000)
0% 100% $1,000
-$250
(Your HealthFund balance)

$750
HealthFund offsets $250 of annual deductible; you pay remaining $750 to meet deductible. Once deductible is met, you and the plan share remaining cost ($50,000 - $1,000 = $49,000).
Coinsurance
(next $12,500)
80% 20% $2,500
After the deductible, the plan pays 80% BUT your share is capped by the medical out-of-pocket maximum of-- $2,500.
Claim $$ above employee coinsurance limit
(next $36,500)
100% 0% $0
Once you reach the medical out-of-pocket maximum, the plan pays covered expenses at 100% for the rest of the calendar year.

Plan pays: $46,500
HealthFund pays: $250
Your share: (deductible plus coinsurance): $3,250

 

* Since the HealthFund is not used to pay for prescription drugs, you can use your HealthFund balance toward other medical expenses throughout the year.

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