Out of Pocket Maximum

JHoward

Expert
25
I need some help figuring something out. My employer offers a United Health Care Choice Plus plan with $1000 individual deductible, $3000 family deductible.

When I sign myself and family up for coverage, does the $3000 family deductible apply to each accident/illness even if only one person is involved?

Also, the plan comes with a $4000 individual out of pocket maximum and a $8000 family oop maximum. Under the family plan, if only ONE person suffers and illness/accident, does the $4000 oop or the $8000 oop maximum apply?

I'm confused.
 
The $3000 family cap means if you have 5 people in your family, and all 5 are in the car when the truck runs over you, only 3 have to meet the deductible.

You can let the carrier pick which 3 . . .

When one of you is run over by the truck, your total OOP is the deductible ($1000) plus coinsurance up to the $3000 OOP limit.

If you have copays and other deductibles (such as for Rx) those are in addition to your major med deductible & OOP limits.
 
Thank you for the reply!

If only one person is injured/becomes ill, and we have paid the $1000 deductible and met the $4000 individual out of pocket maximum (let's assume we're staying in-network for all this) for that individual, then we pay no more, correct? The $8000 family oop maximum does not apply because only one individual is involved (even though we have a family policy), correct?

What if the same individual suffers two separate accidents or illnesses in during the policy year? Do we pay JUST the $1000 individual deductible, or do we pay two $1000 deductibles (since we have to pay up to 3 $1000 deductibles under the family plan). If one individual suffers multiple (unrelated) claims, does the $4000 individual out of pocket maximum apply or the $8000 family oop max?
 
Thank you for the reply!

If only one person is injured/becomes ill, and we have paid the $1000 deductible and met the $4000 individual out of pocket maximum (let's assume we're staying in-network for all this) for that individual, then we pay no more, correct? The $8000 family oop maximum does not apply because only one individual is involved (even though we have a family policy), correct?

What if the same individual suffers two separate accidents or illnesses in during the policy year? Do we pay JUST the $1000 individual deductible, or do we pay two $1000 deductibles (since we have to pay up to 3 $1000 deductibles under the family plan). If one individual suffers multiple (unrelated) claims, does the $4000 individual out of pocket maximum apply or the $8000 family oop max?

For most plans it will be set up as an individual deductible and family OOP max. If one person hits the deductible and co-insurance they are done! I'm pretty sure your plan will be set up like this, be sure to read the policy in detail though to make sure.

Also, does it say that the OOP Max includes your deductible or is it in addition to your deductible? I've seen both! If it's in addition to your deductible the your max OOP would be 5k per person per year.
 
If you have copays, or separate deductibles (such as for Rx, hospital admission, etc.) then those amounts do not accrue toward the deductible or out of pocket maximum.
 

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