To better understand the coverage provided under the HDHP, it's important to know these key terms.
The deductible is a specified annual dollar amount you must pay for covered medical services before the plan begins to pay benefits. The HDHP has a much higher deductible than the PPO and EPO medical options available through the Board of Pensions.
- HDHP deductibles are flat amounts,
as shown on the Key Provisions chart.
- If you enroll any family members, you are responsible for paying the entire family deductible before the plan pays benefits for care that is not preventive. There is no individual deductible amount that applies when one or more eligible family members are enrolled in the HDHP.
- You can reduce your deductibles by completing
Call to Health, a well-being initiative that focuses on the four dimensions of wholeness: spiritual, health, financial, and vocational.
- Under the HDHP, the deductible applies to all your covered medical expenses — including doctor's office visits (in-person or virtual) and prescription drugs —
- preventive care, which is covered 100 percent when network providers are used; and
- certain preventive prescription drugs (see the Preventive Drug List), for which you pay a flat-dollar copay (see Copay below).
- When you enroll in the HDHP, you may set up and contribute to a
health savings account (HSA), and use your HSA funds to pay for your deductible and other eligible medical expenses. Your employer may offer an HSA in which you can participate, or you may set up an HSA on your own.
A copay is a flat dollar amount that you pay upfront for certain services when using network providers.
- Under the HDHP, you pay a copay for certain preventive prescription drugs.
- The copay amount is based on whether the drug is a generic or formulary brand.
Read more details.
Coinsurance (previously referred to as a
copayment) is the percentage of the cost for covered services that you pay after meeting the deductible:
- Your coinsurance for network medical services is 20 percent.
- Your coinsurance is 30 percent for non-preventive generic and formulary prescription drugs.
- The HDHP does not cover out-of-network care or non-formulary prescription drugs.
Total maximum out-of-pocket
The total maximum out-of-pocket is the most you will pay in a year in the form of deductibles, copays, and coinsurance. If your covered out-of-pocket expenses reach the total maximum out-of-pocket amount, the plan will pay 100 percent of allowable costs for the rest of the year.
- The HDHP individual and family total maximum out-of-pocket amounts are
shown on the Key Provisions chart.
- Unlike the deductible, if any one covered family member's expenses reach the Member-only total maximum out-of-pocket amount before the family total maximum out-of-pocket is reached, the plan will pay 100 percent of covered expenses for that family member for the rest of the year.
- Expenses that count toward the HDHP total maximum out-of-pocket include your deductibles, coinsurance, and preventive prescription drug copays.