also call Customer Service if you have questions about payments that count towards the calendar year out-of-pocket maximum. Once the maximum has been reached, covered expenses of the type that count towards the maximum will be paid at 100% of the allowed amount. There may be many expenses you are required to pay under the plan that do not count towards the calendar year out-of-pocket maximum, and that you must continue to pay even after you have met the calendar year out-of-pocket maximum. The following are some examples: •
Out-of-network coinsurance on most services;
•
Copayments;
•
Amounts paid for non-covered services or supplies;
•
Amounts paid for services or supplies in excess of the allowed amount (for example, an out-of-network provider requires you to pay the difference between the allowed amount and the provider's total charges);
•
Amounts paid for services or supplies in excess of any plan limits (for example, a limit on the number of covered visits for a particular type of provider); and,
•
Amounts paid as a penalty (for example, failure to precertify).
The calendar year out-of-pocket maximum applies on a per person per calendar year basis, subject to an in-network maximum of $9,000 or an out-of-network maximum of $12,000 per family in any one year The calendar year family out-of-pocket maximum is an aggregate dollar amount. This means that all amounts that count towards the individual calendar year out-of-pocket maximum will count towards the family aggregate amount. Once the family calendar year out-of-pocket maximum is met, affected benefits for all covered family members will pay at 100% of the allowed amount for the remainder of the calendar year.
Lifetime Maximum There is no lifetime dollar maximum on essential health benefits under the plan.
Other Cost Sharing Provisions The plan may impose other types of cost sharing requirements such as the following: •
Copayments: A copayment is a fixed dollar amount you must pay on receipt of care. The most common example is the office visit copayment that must be satisfied when you go to a doctor's office.
•
Coinsurance: Coinsurance is the amount that you must pay as a percent of the allowed amount. A common example is the percentage of the allowed amount that you must pay when you receive other covered services.
•
Amounts in excess of the allowed amount: As a general rule, and as explained in more detail in Definitions, the allowed amount may often be significantly less than the provider's actual charges. You should be aware that when using out-of-network providers you can incur significant out-of-pocket expenses as the provider has not contracted with us or their local Blue Cross and/or Blue Shield plan for a negotiated rate and they can bill you for amounts in excess of the allowed amount. For example: Out-of-network provider claims may include expensive ancillary charges (billed by the facility or a physician) such as implantable devices for which no extra reimbursement is available as these charges are not separately considered under the plan. This means you will be responsible for these charges.
Out-of-Area Copayments and Coinsurance When you obtain health care services through the BlueCard Program outside of the Alabama service area, the amount you pay for covered services is calculated on the lower of:
9