ALERT! Prescription drug costs do not count toward your medical out-of-pocket limit. See Your Prescription Drug Out-of-Pocket Limit.
How Does It Work?
The medical out-of-pocket limit is the most you pay during a calendar year for covered services from preferred providers. After you meet your medical out-of-pocket limit for the year, the plan pays covered services by preferred providers at 100% of the allowed amount. Expenses are counted from January 1, 2017, or your first day of enrollment, whichever is later; and December 31, 2017, or your last day of enrollment, whichever is first.
How Much Is the Medical Out-of-Pocket Limit?
||How much is it?
|Employees and retirees not enrolled in Medicare, including dependents
||$2,000 per person
$4,000 per family* (2 or more enrolled)
|Retirees enrolled in Medicare Part A and Part B, including dependents
||$2,500 per person
$5,000 per family* (2 or more enrolled)
* Family means all members combined under one subscriber's account.
What Counts Toward Your Medical Out-of-Pocket Limit and What Doesn't?
|What counts toward the medical out-of-pocket limit?
|What doesn’t count toward the medical out-of-pocket limit?
See “Exceptions: Out-of-Network Provider Services That Count” below.
- Amounts paid by the plan, including services covered in full (preventive).
- Prescription drug costs, including the prescription drug deductible (which is counted separately by Washington State Rx Services). See Your Prescription Drug Out-of-Pocket Limit.
- Your coinsurance paid to out-of-network providers (note that out-of-network coinsurance does count toward your medical deductible).
- Balance billed amounts (see definition of balance billing below). For exceptions, see “Exceptions: Out-of-Network Provider Services That Count” below.
- Services not covered by the plan.
- Amounts that are more than a maximum dollar amount paid by the plan. For example, the plan pays a maximum of $150 for adult vision hardware once every two calendar years. Any amount you pay over $150 does not count toward the medical out-of-pocket limit.
- Amounts paid for services exceeding a benefit limit. For example, the benefit limit for acupuncture is 16 visits. If you have more than 16 acupuncture visits in one year, you will pay in full for those visits, and what you pay will not count toward this limit. See Limited Benefit for more benefits with this type of limit.
|What will I pay for after reaching my medical out-of-pocket limit?
||You will still be responsible for paying numbers 3–7 above after you meet your medical out-of-pocket limit. See how the prescription drug out-of-pocket limit works.
Balance billing is a provider billing you for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. Preferred and participating providers may not balance bill you for covered services above the allowed amount. See an example of how this works.
You Still Pay For Out-of-Network Provider Services
Services by out-of-network providers are paid by the plan at 60% of the allowed amount (unless noted under “Exceptions: Out-of-Network Provider Services That Count” below). Even after you meet your medical out-of-pocket limit, you will pay 40% coinsurance for out-of-network provider services and the provider may still balance bill you (see definition above). Note that the 40% you pay and balance billed amounts do not count toward your medical out-of-pocket limit. However, coinsurance paid to out-of-network providers does count toward your medical deductible. Balance billed amounts never apply toward your medical deductible.
Exceptions: Out-of-Network Provider Services That Count
In certain cases, your coinsurance and balance billed amounts for out-of-network provider services will count toward your medical out-of-pocket limit. In addition, the plan will pay 100% of billed charges for these services after you meet your medical out-of-pocket limit.
- Services for which you have an approved network waiver.
- Cochlear Implant Processor Supplier.
- Ocularists (creation and fitting of prosthetic eyes).