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How the deductible works

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NOTE: All of the following examples apply to the HMO Blue New England Deductible Options Deductible plan only.

How does the deductible works between tiers for an individual?
During the course of the plan year, a member with the Blue Options deductible plan may receive care from hospital providers in different tiers. The deductible they are responsible for is determined by the tier of the hospital they choose. All deductible payments, regardless of tier, cross accumulate during the year, minimizing the member's out-of-pocket costs.

Scenario 1
In Scenario 1, the member first receives care at an SBT hospital and pays their $500 SBT deductible.

They subsequently get an outpatient surgery at a BBT hospital. Because the earlier $500 deductible payment accumulates toward the deductible on all tiers, the member is only responsible for the remaining $1,500 of their $2,000 BBT deductible. They are also responsible for their $1,000 copayment.

The member only pays their copayment for any additional admissions (up to their $5,000 out-of-pocket maximum) because the member has already satisfied their deductible.

Date of Service Type of Service Member Responsibility Total Toward $5,000 Out-of-Pocket Maximum
Deductible Copay Total
January 15, 2010 Inpatient admission at an SBT general hospital $500 $150 $650 $650
March 10, 2010 Outpatient surgery at a BBT hospital surgical day care unit $1,500 $1,000 $2,500 $3,150
May 1, 2010 Inpatient admission at a BBT general hospital $0 $1,000 $1,000 $4,150

Scenario 2
In Scenario 2, the member first receives care at BBT hospital and pays their $2,000 BBT deductible and $1,000 copayment.

The member is not responsible for a deductible for the remainder of the year, regardless of the facility's tier. This is because the $2,000 in deductible payments satisfies both the $500 SBT deductible and the $2,000 BBT deductible. There is no deductible on EBT care or at freestanding surgical or imaging facilities.

For the remainder of the year, the member would only have to pay their copayments (up to their $5,000 out-of-pocket maximum).

Date of Service Type of Service Member Responsibility Total Toward $5,000 Out-of-Pocket Maximum
Deductible Copay Total
January 15, 2010 Inpatient admission at an BBT general hospital $2000 $1000 $3000 $3000
April 15, 2010 Outpatient surgery at a BBT hospital surgical day care unit $0 $150 $150 $3,150
May 1, 2010 Inpatient admission at a SBT general hospital $0 $150 $150 $3,300

Scenario 3
In Scenario 3, the member chooses the lowest cost providers for both their MRI and outpatient surgical care. With both a freestanding surgical facility and an EBT hospital, the member only pays copayments totaling $200.

When the member gets a subsequent MRI at a BBT facility, they are responsible for the full $1,400 cost of the service. They do not have to pay the remaining $600 of their deductible or their copayment because the cost of the service was only $1,400.

When the member is admitted to a BBT hospital later in the year, they are responsible for the $600 that remains on their deductible and for their $1,000 copayment.

The member is not responsible for a deductible for the remainder of the year, regardless of the facility's tier. This is because the total of $2,000 in deductible payments satisfies the $500 SBT deductible and the $2,000 BBT deductible. There is no deductible on EBT care or at freestanding surgical or imaging facilities.

For the remainder of the year, the member would only have to pay their copayments (up to their $5,000 out-of-pocket maximum for copayments over $100).

Date of Service Type of Service Member Responsibility Total Toward $5,000 Out-of-Pocket Maximum
Deductible Copay Total
January 3, 2010 MRI at imaging facility not associated with a hospital $0 $50 $50 $0
January 15, 2010 Outpatient service at an ambulatory surgical facility (not associated with a hospital) $0 $150 $150 $150
April 1, 2010 MRI test at a BBT general hospital $1,400* $0* $1,400 $1,550
December 1, 2010 Inpatient admission at a BBT general hospital $600 $1,000 $1,600 $3,150

* Reflects the actual cost. Members do not have to pay more than the actual cost of the service on a visit.

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How does the deductible works between tiers for family?
During the course of the plan year, Blue Options deductible plan family members may receive care from hospital providers in different tiers.

The member only pays their copayment for any additional admissions (up to their $5,000 out-of-pocket maximum) because the member has already satisfied their deductible.

Members are responsible for a deductible, which is determined by the tiers of the hospitals they choose. All deductible payments, regardless of tier, cross accumulate toward both the individual as well as the family deductibles. And deductible payments on one tier can help satisfy the deductible requirements on other tiers, helping to minimize out-of-pocket costs. No deductible applies in the EBT.

Scenario 4
In Scenario 4, John and Sue pay the deductibles and copayments when they get care. Their deductibles, as well as their copays, are based on the tiers of the facilities they choose. In total, they pay $2,500 in deductible payments. They also pay $1,150 in copays.

When their daughter Cindy gets care later in the year, she does not have to pay a deductible for her care at an SBT facility, but is responsible for a copayment. This is because the deductibles accumulate across tiers, as well as for the family as a whole. The $2,500 in deductibles that John and Sue paid satisfies the $1,000 family deductible for the SBT.

Date of Service Member Name Type of Service Member Responsibility Deductible Met Year-to-Date Out-of-Pocket Maximum Met Year-to-Date
Deductible Copay Total IND FAM IND $5,000 FAM $10,000
January 15, 2010 John Outpatient service at an SBT hospital surgical day care unit $500 $150 $650 $500 $500 $650 $650
March 1, 2010 Sue Outpatient service at a BBT hospital surgical day care unit $2,000 $1,000 $3,000 $2,000 $2,500 $3,000 $3,650
May 1, 2010 Cindy Inpatient admission at an SBT general hospital $0† $150 $150 $0† $2,500 $150 $3,800

† Since the $1,000 SBT family deductible was previously satisfied by John and Sue, Cindy only needed to pay the $150 copayment.

Scenario 5
When their daughter Cindy gets care at a BBT facility later in the year, she is responsible for the remaining $1,500 BBT deductible and her $1,000 copayment. Because the deductibles accumulate, John and Sue's previous $2,500 in payments help satisfy the $4,000 family BBT deductible.

The family is not responsible for deductibles for the remainder of the year. This is because the deductible payments accumulate and payments for care on one tier can be used to satisfy the deductible requirements of other tiers. The family would, however, be responsible for their copayments up to the $10,000 family or $5,000 individual out-of-pocket maximum.

Date of Service Member Name Type of Service Member Responsibility Deductible Met Year-to-Date Out-of-Pocket Maximum Met Year-to-Date
Deductible Copay Total IND FAM IND $5,000 FAM $10,000
February 5, 2010 John Outpatient service at an SBT hospital surgical day care unit $500 $150 $650 $500 $500 $650 $650
March 12, 2010 Sue Outpatient service at a BBT hospital surgical day care unit $2,000 $1,000 $3,000 $2,000 $2,500 $3,000 $3,650
October 1, 2010 Cindy Inpatient admission at a BBT general hospital $1,500 $1,000 $2,500 $1,500 $4,000 $2,500 $6,150
December 15, 2010 John Inpatient admission at an EBT general hospital $0 $150 $150 $0 $0 $800‡ $6,300

‡ Reflects the $150 copayment and the $650 in earlier deductible and copayments.

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