Terms to Know
Each family member covered under the plan must meet the deductible each calendar year. The deductible does not include copays, amounts exceeding the maximum allowable amount (MAA), prescription drug expenses, or expenses not covered by the plan.
Example: The individual deductible for the YNHHS Medical Plan is $3,500. When two covered members of your family have each met their $3,500 deductible, the $7,000 family deductible for the year will have been met. From then on, the plan will pay its share of costs for them and any other covered family member during that calendar year.
Dependent Children Over Age 26
Example: You typically receive preventive care during an annual checkup. If a preventive screening yields an abnormal result, you may receive diagnostic care to determine why.
Maximum Allowable Amount (MAA)
The facilities, providers, and suppliers that Anthem Blue Cross and Blue Shield has contracted with to provide health care services. The YNHHS plans have two types of in-network providers:
- The Signature network includes: YNHHS facilities/hospitals, PCP’s from NEMG, Community Medical Group (CMG), Yale Medicine (YM), WestMed in CT, Trinity Health of New England hospitals and affiliated physicians. Also included are specialists from YM, NEMG, CMG and Trinity Health, and those credentialed at YNHHS.
- Anthem Preferred Provider Organization (PPO) includes providers and facilities in Anthem’s Century Preferred network.
Any cost or fee that you pay for medical services, prescription drugs, or medical supplies. These include your annual deductible, and copays and coinsurance.
The out-of-pocket maximum does not include benefit reductions due to failure to receive prior authorization, covered expenses paid at 100%, expenses exceeding the maximum allowed amount (MAA), expenses not covered by the plan, or employee premium contributions.
Preferred Provider Organization (PPO)
Primary Care Physician
Qualifying Life Event
Examples include allergist, cardiologist, dermatologist, orthopedist, podiatrist, ear/nose/throat, gastroenterologist, OB/GYN, ophthalmologist.