What You Need to Know About the HDHP
- Preventive medical care is covered at 100% with no deductible when you use an in-network provider.
- For non-preventive care—and non-preventive drugs—you pay for your expenses until you reach your deductible: $1,500 for individual coverage or $3,000 for family coverage.
- You must first meet your deductible: $1,500 for individual coverage or $3,000 for family coverage for your medical and prescription drug expenses before the HDHP begins to pay for covered services.
- If one or more family members are covered in addition to yourself, you reach the family deductible when total expenses reach $3,000, no matter how the expenses are spread across the family. The entire $3,000 family deductible must be met, even if only one family member has claims. There is no individual deductible when you elect family coverage.
- After you reach the deductible, any additional medical expenses are shared between the Plan and you as “coinsurance.” The Plan’s coinsurance is 90% and your coinsurance is 10%.
- When your coinsurance, plus deductible and prescription copay reaches the out-of-pocket maximum, the Plan pays 100% of your remaining in-network covered medical services, including prescription drug costs, for the rest of the calendar year. The “out-of-pocket maximum” for in-network expenses is $3,550 for individual coverage or $7,100 for family coverage. For family coverage, the entire $7,100 out-of-pocket maximum must be met, even if only one family member has claims.
To get the most value from your HDHP, be sure to enroll in a Health Savings Account (HSA).
|High Deductible Health Plan (HDHP) vs. Choice Plus Plans|
|Plan Provision||Choice Plus Plans||High Deductible Health Plan (HDHP)|
|Monthly Payroll Contributions||Higher||Lower|
|In-Network Preventive Care||Covered at 100% with no deductible in all plans|
|In-Network Physician Office Visits||$30 copay per||Covered at 90% after the deductible|
Preventive Prescription Drugs at Retail Pharmacy or Mail Order
|Copays; not subject to the deductible|
|Non-Preventive Prescription Drugs at Retail Pharmacy or Mail Order||Only copays apply||Covered with copays after meeting the deductible|
|Health Savings Account (HSA)||Not available if you elect any of the Choice Plus plans.|
Save up to $3,450* single/$6,900* family on a
|Healthcare Flexible Spending Account (FSA)||Set aside up to $2,600* per year on a pre-tax basis to pay|
for healthcare expenses during a single calendar year.
Roll over up to $500 from one year to the next.
|Not available if you elect the HDHP with an HSA.|
You cannot elect an HSA and an FSA in the same
calendar year, or elect an HSA and have an FSA
balance rollover in the same calendar year.
Important! Most out-of-network services are covered at 60%* of 190% of the Medicare Maximum Allowable Charge (MAC) after the annual deductible for out-of-network services has been met.
- You are responsible for obtaining precertifications from UHC before most non-office visit treatment begins (unless it is an emergency). If you do not request precertification before having inpatient or outpatient surgery and/or certain treatment, you will be subject to a $500 penalty. If you are having trouble finding providers and/or services in the network, please call UHC at 800-232-9357. In an emergency, if you or your covered dependent is admitted to a non-network hospital, you must contact UHC within 48 hours of admission or you will be subject to a $500 penalty.
- Before the Plan starts to pay anything for out-of-network services, you must meet your out-of-network deductible.
- Then the Plan pays coinsurance of 60%* of remaining covered charges up to a maximum of 190% of the Maximum Allowable Charge (MAC).
- If you reach the out-of-network out-of-pocket maximum, the Plan will pay 190% of the Medicare MAC.
Note: For the Choice Plus 80, 90 and 100 plans, your out-of-network expenses can be used to satisfy the in-network deductible and in-network out-of-pocket maximum. For the HDHP, these expenses do not satisfy the in-network deductible and out-of-pocket maximum.
* 70% for outpatient mental health/substance abuse services.
Medicare Maximum Allowable Charge (MAC)
Out-of-network services in the healthcare plans are indexed to 190% of the Medicare MAC. Out-of-network services for all medical plan options are covered at 60% of 190% of the Medicare MAC, except for mental health and substance use disorder outpatient counseling and outpatient programs which are covered at 70% of 190% of the Medicare MAC.
Here’s an example: Your out-of-network physician charges you $200 for an office visit. The claim submitted to UHC has a billing code of 99212 (office visit for an established patient in ZIP code 10010 in New York City) 190% of the Medicare MAC for this billing code is $95.87. Therefore, $95.87 (not $200) is the basis for the out-of-network reimbursement.
- If you had not met the out-of-network annual deductible, you would be responsible to pay the full $200, and $95.87 would be applied to the out-ofnetwork deductible.
- If you had already met the out-of-network annual deductible, the plan would pay the coinsurance of 60% of $95 .87, which is $57.22. Your share of the coinsurance is 40% of $95.87, which is $38.35. You are also responsible to pay the amount in excess of the 190% of the Medicare MAC; that is $200 - $95.87 = $104.13. In total, you would pay $38.35 + $104.13 = $142.48, and $38.35 would be applied toward your out-of-pocket maximum.
- If you had met the out-of-network annual out-of-pocket maximum, the medical carrier would pay 190% of the Medicare MAC ($95.87), and you would be responsible for the balance ($104.13). Charges in excess of 190% of the Medicare MAC (in this example, $104.13) do not count toward the out-of-network out-of-pocket maximum. For information on specific Medicare MAC(s) talk to your physician or his/her office staff
- Any charges exceeding plan limits do not count toward the out-of-pocket maximum, including any charges exceeding 190% of the Medicare MAC.
- You can find out how much you will be reimbursed for out-of-network services before you seek treatment by first asking your physician for the medical “procedure code” along with the associated fee. Then, call UHC’s member services to request an estimate of their reimbursement.