Common use of Maximum Out of Pocket Clause in Contracts

Maximum Out of Pocket. The [Tier 1 and Tier 2] Per Member and [Tier 1 and Tier 2] Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. For Single Coverage Only: [Tier 1] In the case of single coverage, for a Member, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Single Coverage Only: [Tier 2] In the case of single coverage, for a Member, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. [All per Member Cash Deductible plus Coinsurance and Copayments applied to the [Tier 1] per Member Maximum Out of Pocket also apply to this [Tier 2] per Member Maximum Out of Pocket.] Once the [Tier 2] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Other than Single Coverage: [Tier 1] In the case of coverage which is other than single coverage, for a Member, the [Tier 1] per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1] Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1] Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year. For Other than Single Coverage: [Tier 2] In the case of coverage which is other than single coverage, for a Member, the [Tier 2] per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as [Tier 2] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 2] per Member Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 2] Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. [Note that amounts applied to the [Tier 1] per Member Maximum Out of Pocket also apply to this [Tier 2] per Member Maximum Out of Pocket.] In the case of coverage which is other than single coverage, for a Covered Family, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as [Tier 2] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 2] per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 2] Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year. [Note that amounts applied to the [Tier 1] per Covered Family Maximum Out of Pocket also apply to this [Tier 2] per Covered Family Maximum Out of Pocket.]] [Note to carriers: Use the above text for cash deductible, family limit and MOOP if the plan is issued as a tiered high deductible health plan that could be used in conjunction with an HSA.] Impact of the Consolidated Appropriations Act (CAA) on Copayments, Deductible Amounts, and/or Coinsurance, Maximum Out of Pocket Amounts and Balance Billing

Maximum Out of Pocket. The [Tier 1 and Tier 2] Per Member and [Tier 1 and Tier 2] Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. For Single Coverage Only: [Tier 1] In the case of single coverage, for a Member, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Single Coverage Only: [Tier 2] In the case of single coverage, for a Member, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as per Member Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. [All per Member Cash Deductible plus Coinsurance and Copayments applied to the [Tier 1] per Member Maximum Out of Pocket also apply to this [Tier 2] per Member Maximum Out of Pocket.] Once the [Tier 2] per Member Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. For Other than Single Coverage: [Tier 1] In the case of coverage which is other than single coverage, for a Member, the [Tier 1] per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Member Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1] Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. In the case of coverage which is other than single coverage, for a Covered Family, the [Tier 1] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as [Tier 1] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 1] per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 1] Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year. For Other than Single Coverage: [Tier 2] In the case of coverage which is other than single coverage, for a Member, the [Tier 2] per Member Maximum Out of Pocket is the annual maximum dollar amount that a Member must pay as [Tier 2] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 2] per Member Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 2] Deductible or Coinsurance or Copayments will be required for such Member for the rest of the Calendar Year. [Note that amounts applied to the [Tier 1] per Member Maximum Out of Pocket also apply to this [Tier 2] per Member Maximum Out of Pocket.] In the case of coverage which is other than single coverage, for a Covered Family, the [Tier 2] Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as [Tier 2] per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the [Tier 2] per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further [Tier 2] Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year. [Note that amounts applied to the [Tier 1] per Covered Family Maximum Out of Pocket also apply to this [Tier 2] per Covered Family Maximum Out of Pocket.]] [Note to carriers: Use the above text for cash deductible, family limit and MOOP if the plan is issued as a tiered high deductible health plan that could be used in conjunction with an HSA.] Impact COVERED SERVICES & SUPPLIES [Members] are entitled to receive the benefits in the following sections when Medically Necessary and Appropriate, subject to the payment by [Members] of applicable copayments [Cash Deductible,][or Coinsurance] as stated in the Consolidated Appropriations Act (CAA) on Copaymentsapplicable Schedule of Services and Supplies and subject to the terms, Deductible Amountsconditions and limitations of this Contract. Read the entire Contract to determine what treatment, and/or Coinsurance, Maximum Out of Pocket Amounts services and Balance Billingsupplies are limited or excluded.