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 hospitals/facilities (owned or jointly owned), Trinity Health of New England owned or jointly owned hospitals/facilities (CT locations only), PCP’s from Community Medical Group (CMG), NEMG, Trinity Health of New England and SoNE HEALTH (CT locations only), WestMed, Yale Medicine (YM), and Specialists from NEMG, YM, CMG, Trinity, and those that have medical staff privileges at a YNHHS facility.
- 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 most you will pay in a calendar year for medical or prescription drug expenses. Once the out-of-pocket maximum has been met, the plan pays 100% of covered expenses for the covered person or family for the remainder of the calendar year, including copays and expenses that are applied toward the annual deductible.
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.