There is a federal maximum out-of-pocket limit of $8,700 for a single person and $17,400 for a family plan. This means that for covered medical services, one person will never accumulate more than $8,700 in out-of-pocket costs* per benefit year, and a family will never accumulate more than $17,400 in out-of-pocket costs* per benefit year. The federal out-of-pocket limit does not include premium costs, balance billed amounts from out-of-network providers, or any other out-of-network cost-sharing.
Our HSA plans have an aggregate deductible. This means if more than one person is covered by the plan, the “per person” deductible and maximum out-of-pocket limit does not apply. The family deductible must be met before Quartz will pay benefits. One person may accumulate to the entire family deductible. However, one person will not pay more than the federal maximum out-of-pocket limit of $8,700.
Terminology
Deductible – The amount you must pay for covered health care before Quartz begins to pay.
Coinsurance – The percentage you pay for a covered health care service after you have met your deductible.
*Maximum Out-of-Pocket (MOOP) – The most you will have to pay during a policy period for health care services.
Does not include premiums or balance billing for out-of-network services. After you reach this amount, your health plan will pay 100% for all covered benefits on the plan. Please refer to your policy documents (Certificate of Coverage, Summary of Benefits and Coverage, any Benefit Riders, etc.) for a list of covered benefits.
Copayment (or Copay) – A fixed amount you pay for a covered health care service, usually at the time you receive the service. The amount may vary depending on the type of service you receive.
Usual, Customary, and Reasonable Charge (UCR) – The amount your health plan will pay for a medical service in a geographic area based on what other providers in that area usually charge for the same kind of service. You may be responsible for paying charges that are above the UCR and other out-of-pocket costs.
Aggregate Plans: Family PLan
Example 1 – Bronze HSA
In this example, the single deductible and single MOOP do not apply because it is an aggregate family plan. Person 1 will only pay the first $8,700 of the bill. They are not responsible for the full family MOOP of $13,500 because the per person federal MOOP is $8,700. Once Person 1 meets their per person federal MOOP, all covered services are covered at 100% for the remainder of the benefit year. The remaining members of the family will continue to pay their deductible until their combined out-of-pocket reaches the family MOOP of $13,500.
Family Deductible = $13,500
Coinsurance = 0%
Single MOOP = $6,750
(does not apply on family plan, single federal MOOP applies)
Per person federal MOOP = $8,700
Family MOOP = $13,500
AGGREGATE PLANS – FAMILY PLAN
EXAMPLE 2 – GOLD HSA
In this example, the single deductible and single MOOP do not apply because there is more than one member on the plan. Person 1 will pay the first $4,000 of the bill because the family deductible is $4,000. Person 1 will now pay 10% until they reach the federal MOOP of $8,700. Person 1 will never pay the full family MOOP of $13,300 because the federal MOOP for one person is only $8,700. The family deductible has been met by Person 1, so the rest of the family members will pay 10% for covered services until the family’s combined out-of-pocket reaches the family MOOP of $13,300.
Family deductible = $4,000
Coinsurance = 10%
Family MOOP = $13,300
Single MOOP = $6,650
(Does not apply on family plan;
single federal MOOP applies)
Per person federal MOOP =
$8,700
AGGREGATE PLANS – SINGLE PLAN
EXAMPLE 3 – GOLD HSA
Person 1 is on a Single Gold Deductible plan and has high healthcare expenses totaling $60,000. Person 1 is responsible for the first $2,000 (deductible) and is then responsible for 10% (coinsurance) of the remaining charges until the maximum out-of-pocket is met. Because there is only one person on this plan and the single MOOP is less than the federal MOOP, Person 1 cannot spend more than the single MOOP of $6,650 on covered medical expenses per benefit year.
(Maximum out-of-pocket (MOOP) on plan is less than federal $8,700 max)
Single deductible = $2,000
Coinsurance = 10%
Single MOOP = $6,650
