Common use of The Cash Deductible Clause in Contracts

The Cash Deductible. For Single Coverage Only Each Calendar Year, a Member must have Covered Services and Supplies that exceed the per Member Cash Deductible before We pay any benefits to the Member for those charges. The per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered can be used to meet the Cash Deductible. Once the per Member Deductible is met, We pay benefits for other Covered Services and Supplies above the Deductible amount incurred by the Member, less any applicable [copayment or] Coinsurance, for the rest of that Calendar Year. But all charges must be incurred while the Member is covered by this Contract. And what We pay is based on all the terms of this Contract including benefit limitations and exclusion provisions.] [Family Deductible Limit: For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of Members in a family meets the Per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Services and Supplies incurred by any member of the covered family, less any [copayment or] Coinsurance, for the rest of that Calendar Year. ] [Note to carriers: Use the above For Single Coverage Only and Other than Single Accumulation, For example, the text would be included if the plan is a high deductible health plan that could be used in conjunction with an HSA] [Maximum Out of Pocket Maximum out of pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services or Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services or Supplies for the remainder of the Calendar Year.] [Once two Members in a family meet their individual Maximum Out of Pocket, no other Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year.] [Tier 1] and [Tier 2] Maximum Out of Pocket [Please note: There are separate Maximum Out of Pocket amounts for [Tier 1] and [Tier 2] as shown on the Schedule.] [Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year.] (Use the above Tier 1 and Tier 2 text if the MOOPS accumulate separately.) [[Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network and [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network or [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] and [Tier 2] Covered Services and Supplies for the remainder of the Calendar Year. (Use the above text if the Tier 1 MOOP can be met separately and the Tier 1 MOOP is also applied toward the satisfaction of the Tier 2 MOOP.)

The Cash Deductible. For Single Coverage Only Each Calendar Year, a Member must have Covered Services and Supplies that exceed the per Member Cash Deductible before We pay any benefits to the Member for those charges. The per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered can be used to meet the Cash Deductible. Once the per Member Deductible is met, We pay benefits for other Covered Services and Supplies above the Deductible amount incurred by the Member, less any applicable [copayment or] Coinsurance, for the rest of that Calendar Year. But all charges must be incurred while the Member is covered by this Contract. And what We pay is based on all the terms of this Contract including benefit limitations and exclusion provisions.] [Family Deductible Limit: For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of Members in a family meets the Per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Services and Supplies incurred by any member of the covered family, less any [copayment or] Coinsurance, for the rest of that Calendar Year. ] [Note to carriers: Use the above For Single Coverage Only and Other than Single Accumulation, For example, the text would be included if the plan is a high deductible health plan that could be used in conjunction with an HSA] [Maximum Out of Pocket Maximum out of pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services or Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services or Supplies for the remainder of the Calendar Year.] [Once two Members in a family meet their individual Maximum Out of Pocket, no other Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year.] [Tier 1] and [Tier 2] Maximum Out of Pocket [Please note: There are separate Maximum Out of Pocket amounts for [Tier 1] and [Tier 2] as shown on the Schedule.] [Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year.] (Use the above Tier 1 and Tier 2 text if the MOOPS accumulate separately.) [[Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network and [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network or [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] and [Tier 2] Covered Services and Supplies for the remainder of the Calendar Year. (Use the above text if the Tier 1 MOOP can be met separately and the Tier 1 MOOP is also applied toward the satisfaction of the Tier 2 MOOP.)) [Maximum Out of Pocket: The Per Member and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Member, the 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 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. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year.] [Note to carriers: Use the above text if the plan is issued as a high deductible health plan that could be used in conjunction with an HSA.] If This Plan Replaces Another Plan The Contractholder who purchased this Contract may have purchased it to replace a plan the Contractholder had with some other carrier. The Member may have incurred charges for covered services and supplies under the Contractholder's old plan before it ended. If so, these charges will be used to meet this Contract’s Cash Deductible if:

The Cash Deductible. For Single Coverage Only Each Calendar Year, a Member must have Covered Services and Supplies that exceed the per Member Cash Deductible before We pay any benefits to the Member for those charges. The per Member Cash Deductible is shown in the Schedule. The Cash Deductible cannot be met with Non-Covered Services and Supplies. Only Covered Services and Supplies incurred by the Member while covered can be used to meet the Cash Deductible. Once the per Member Deductible is met, We pay benefits for other Covered Services and Supplies above the Deductible amount incurred by the Member, less any applicable [copayment or] Coinsurance, for the rest of that Calendar Year. But all charges must be incurred while the Member is covered by this Contract. And what We pay is based on all the terms of this Contract including benefit limitations and exclusion provisions.] [Family Deductible Limit: For Other than Single Coverage The per Member Cash Deductible is not applicable. This Contract has a per Covered Family Cash Deductible which applies in all instances where this Contract provides coverage that is not single only coverage. Once any combination of Members in a family meets the Per Covered Family Cash Deductible shown in the Schedule, We pay benefits for other Covered Services and Supplies incurred by any member of the covered family, less any [copayment or] Coinsurance, for the rest of that Calendar Year. ] [Note to carriers: Use the above For Single Coverage Only and Other than Single Accumulation, For example, the text would be included if the plan is a high deductible health plan that could be used in conjunction with an HSA] [Maximum Out of Pocket Maximum out of pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Covered Services or Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the Maximum Out of Pocket. Once the Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for Covered Services or Supplies for the remainder of the Calendar Year.] [Once two Members in a family meet their individual Maximum Out of Pocket, no other Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year.] [Tier 1] and [Tier 2] Maximum Out of Pocket [Please note: There are separate Maximum Out of Pocket amounts for [Tier 1] and [Tier 2] as shown on the Schedule.] [Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the [Tier 2] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for Covered Services and Supplies for the remainder of the Calendar Year.] (Use the above Tier 1 and Tier 2 text if the MOOPS accumulate separately.) [[Tier 1] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all Tier 1 Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 1] Network Maximum Out of Pocket. Once the [Tier 1] Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 1] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] Covered Services and Supplies for the remainder of the Calendar Year. [Tier 2] Network Maximum Out of Pocket means the annual maximum dollar amount that a Member must pay as Copayment, Deductible and Coinsurance for all [Tier 1] Network and [Tier 2] Network Covered Services and Supplies in a Calendar Year. All amounts paid as Copayment, Deductible and Coinsurance shall count toward the [Tier 2] Network Maximum Out of Pocket. Once the Network Maximum Out of Pocket has been reached, the Member has no further obligation to pay any amounts as Copayment, Deductible and Coinsurance for [Tier 1] Network or [Tier 2] Network Covered Services and Supplies for the remainder of the Calendar Year. Once any combination of Members in a family meet an amount equal to two times the [Tier 2] individual Maximum Out of Pocket, no Member in that family will be required to pay any amounts as Copayments, Deductible or Coinsurance for [Tier 1] and [Tier 2] Covered Services and Supplies for the remainder of the Calendar Year. (Use the above text if the Tier 1 MOOP can be met separately and the Tier 1 MOOP is also applied toward the satisfaction of the Tier 2 MOOP.)) [Maximum Out of Pocket: The Per Member and Per Covered Family Maximum Out of Pocket amounts are shown in the Schedule. In the case of single coverage, for a Member, the 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 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. In the case of coverage which is other than single coverage, for a Covered Family, the Maximum Out of Pocket is the annual maximum dollar amount that members of a covered family must pay as per Covered Family Cash Deductible plus Coinsurance and Copayments for all covered services and supplies in a Calendar Year. Once the Per Covered Family Maximum Out of Pocket has been met during a Calendar Year, no further Deductible or Coinsurance or Copayment will be required for members of the covered family for the rest of the Calendar Year.] [Note to carriers: Use the above text if the plan is issued as a high deductible health plan that could be used in conjunction with an HSA.] If This Plan Replaces Another Plan The Contractholder who purchased this Contract may have purchased it to replace a plan the Contractholder had with some other carrier. The Member may have incurred charges for covered services and supplies under the Contractholder's old plan before it ended. If so, these charges will be used to meet this Contract’s Cash Deductible if: the charges were incurred during the Calendar Year in which this Contract starts or during the 90 days preceding the effective date, whichever is the greater period; this Contract would have provided coverage for the charges if this Contract had been in effect: the Member was covered by the old plan when it ended and enrolled in this Contract on its Effective Date; and this Contract takes effect immediately upon termination of the prior plan.