The Individual deductible you chose is indicated
on your ID card. The table below lists the
deductible and the out-of-pocket limits that
apply to your Policy — based on the Individual
Deductible amount selected by you and printed on
your ID card.
While the Pool does not offer a “Family” Policy,
if you have three or more qualified family
members on Pool Policies with the same
deductible you may receive reduced deductible
and out-of-pocket limits as indicated on the
table below.
Plan Variable (printed
on ID card) |
Individual Deductible
Choice and Family Amount |
Out-of-Pocket Limit
(annual
deductible plus coinsurance) |
|
500 |
Individual = $500
Family = $1,000 |
Individual = $2,500
Family = $5,000 |
|
1,000 |
Individual = $1,000
Family = $2,000 |
Individual = $3,500
Family = $7,000 |
|
2,000 |
Individual = $2,000
Family = $4,000 |
Individual = $5,000
Family = $10,000 |
|
5,000 |
Individual = $5,000
Family = $10,000 |
NA - The Pool pays 100% after
deductible is met |
|
7,500 |
Individual = $7,500
Family = $15,000 |
NA - The Pool pays 100% after
deductible is met |
|
10,000 |
Individual = $10,000
Family = $20,000 |
NA - The Pool pays 100% after
deductible is met |
Note: Amounts applied to the annual
deductible and to member coinsurance are not
used to calculate benefit limitations that are
based on a dollar amount (e.g., $1,500 per
calendar year). Such limits are based on amounts
actually paid out by the Pool. However, when a
limitation is based on a maximum number of days,
visits, or benefit periods (e.g., 30 days per
calendar year), the maximum benefit may be
reached even if all covered charges were applied
to the deductible.
Plan Deductible
See your ID card for your individual deductible
amount.
Deductible — The deductible you chose is
indicated on your ID card (see table,
above). You must pay your deductible amount
before the Pool will begin paying
its share of your covered charges. Only covered
charges are applied toward the
deductible. Covered charges may be less than the
billed amount. If you receive
services from a nonparticipating provider, you
will be responsible for paying the
provider any amounts over the covered charge, in
addition to your deductible.
Family Deductible — An entire family
meets an annual deductible when the
total deductible amount for all family members
reaches two times the Individual
deductible amount chosen (see table, above).
Note: If a member’s Individual deductible
is met, no more charges incurred by that member
may be used to satisfy
the Family deductible.
Change in Deductible Plan — Pool members
can change from a lower to a
higher deductible plan at any time upon written
notice to the Administrator. The
effective date of the change is the next premium
due date following the request
date.
If you increase your deductible amount, the new
deductible amount must be met
for all services received as of the change
effective date. This means that if you
had met your lower deductible and then change to
a higher deductible, for services
received as of the change effective date, you do
not receive benefit payments
until the increase in deductible is met.
Pool members can change from a higher to a lower
deductible plan on or before
October 1 each year. The effective date will be
January 1 the following year. Requests
for such changes must be made in writing to the
Administrator. If you decrease
your deductible amount you do not receive a
refund for any deductible
amounts applied for services before the change
effective date.
|
