Your Liviniti High Deductible Health Plan (HDHP) has a non-embedded deductible and an embedded maximum out-of-pocket (MOOP). Here is what that means:
1. Deductibles (What You Pay Before Insurance Kicks In)
- Single Coverage: If you have employee-only coverage, you must meet your $2,500 deductible before the plan starts sharing costs.
- Family Coverage: If you cover dependents, the family deductible is $5,000 total. However:
- There is no individual deductible limit under family coverage.
- This means one person can contribute all $5,000 to satisfy the family deductible, or multiple family members can contribute to reach that amount.
- Until the full $5,000 family deductible is met, no coinsurance applies to anyone in the family.
2. Maximum Out-of-Pocket (MOOP) (Your Cost Limit for the Year)
Once you reach the MOOP, the plan covers 100% of eligible expenses for the rest of the calendar year.
- Single Coverage: MOOP is $6,750.
- Family Coverage: MOOP is $13,500, but each individual has a cap of $6,750 (this is embedded MOOP).
- This means if one person in the family reaches $6,750 in out-of-pocket costs, they will no longer have to pay for covered services, but the rest of the family still contributes until the total of $13,500 is reached.
Examples –
Example 1: One Person Meets the Deductible Alone
- John has family coverage (spouse and child).
- He incurs $5,000 in medical expenses.
- Because this is a non-embedded deductible, John alone can satisfy the entire family deductible.
- Now that the $5,000 deductible is met, all family members move to coinsurance (the plan starts sharing costs).
Example 2: Multiple Family Members Contribute to the Deductible
- Sarah’s family includes her, her husband, and one child.
- Sarah has $2,500 in medical bills, her husband has $1,500, and their child has $1,000.
- Together, they reach $5,000 total → The family deductible is met.
- Now all three family members move to coinsurance for the rest of the year.
Example 3: Reaching the Maximum Out-of-Pocket (MOOP)
A family of four incurs the following out-of-pocket expenses:
-
- Dad: $6,750
- Mom: $3,000
- Child 1: $2,000
- Child 2: $1,750
- Total = $13,500 (MOOP reached)
- Dad stops paying out-of-pocket after $6,750 because the plan has an embedded individual MOOP.
- The entire family stops paying after hitting $13,500.
- After this, the plan covers 100% of costs for the rest of the calendar year.
Key Takeaways –
- If you cover dependents, there is one family deductible ($5,000) that must be met before coinsurance applies.
- One person or multiple people can reach the family deductible.
- Maximum out-of-pocket is embedded, meaning once one family member hits $6,750, their expenses are fully covered.
- Once the family reaches $13,500 in out-of-pocket costs, all covered expenses are 100% paid for the rest of the calendar year.