How the High Deductible Plan works

  1. There are two deductible thresholds: $2000 for single & $4000 for family (more than one )
  2. Preventative services (physicals, mammograms, etc.) are covered at 100% with no cost to insured unless they become diagnostic, in which case they are not.*
  3. Insured will be responsible for Cigna negotiated price for these services as long as we stay in network.
  4. Until you reach the deductible threshold, all bills (in & out of network medical services and prescriptions) are paid by the insured person, not the BOE.
  5. Negotiated prices will count towards the $2000/$4000 deductible threshold.
  6. Insured are responsible for entire out of network costs until $2000/$4000 deductible threshold is met.
  7. Out of network doctor visits will be credited towards deductible threshold at the maximum reimbursable charge (MRC).
  8. Once the 2000/$4000 deductible threshold is met, all in-network medical services will be covered by BOE.
  9. After the deductible threshold is met, insured are still responsible for:
  10. 20% of out of network fees and BOE will pay 80% amaximum reimbursable charge (MRC) for that service. Providers may still balance bill for the difference between what they charged and the MRC.  How it works
  11. The limit for out of network medical is based on 20% of MRC for services, $2000 single and $4000 family above the basic $2000/$4000 deductible threshold.
  12. Insured will still have to pay for prescriptions but will follow the $10/$30/$45 formula until a further $1000/$2000 expenditure limit is reached.

Example: if a family plan member spends $4000 in a combination of in and out of network visits, blood tests and prescriptions (paid at full negotiated price) they would not be charged for any further in-network services.

They would still have to pay the $10/$30/$45 co-pay for prescriptions until they had spent a further $2000 on prescriptions & would have to pay for out of network medical services at 20% of MRC for a further $4000.

Maximum possible they could expend in an insurance year from Sept to Aug would be $10,000 for family or $5,000 for single.

* Example: if you are at a physical and the doctor notices that you have some strange spot and sends you for more tests, the original physical will be charged as a diagnostic session and will be counted towards the deductible.