Catastrophic Plan: Cost of Coverage
This section will help participants understand how they pay for medical coverage under the Catastrophic plan.
Annual Deductible
The "deductible" is the initial $2,000 each participant must pay for medical services he or she receives each calendar year before the plan begins to pay benefits.
The annual deductible is waived for certain services provided by in-network physicians, including certain routine lab and X-ray, related to routine mammograms, routine pap smears and psa/dre. The annual deductible is also waived for home health care and hospice care.
Under certain conditions, the participant is allowed to carry over eligible expenses from one year to the next. If the participant incurs expenses in October, November or December and has not yet met the annual deductible for that year, those expenses will be carried over and applied to the following year's annual deductible.
Common Accident Deductible
If two or more covered family members are injured in the same accident, only one individual deductible for all family members involved will be applied to the eligible expenses resulting from the accident. The deductible will be applied only to those accident-related medical expenses incurred during the calendar year in which the accident occurs.
Coinsurance
"Coinsurance" is the percentage of eligible expenses a participant pays for medical services once the participant meets the annual deductible.
Annual Out-of-Pocket Maximum
The "out-of-pocket maximum" is the amount of coinsurance payments a participant must pay each calendar year before the Catastrophic plan begins paying 100% of eligible expenses up to the negotiated rate (for in-network providers). This maximum is designed to protect a participant from catastrophic costs. See "Network Benefits" in the SAIC Catastrophic section for more information about negotiated rates.
The following expenses do not count toward a participant's annual out-of-pocket maximum:
- Payments for eligible expenses incurred in a different calendar year;
- Copayments a participant makes for eligible expenses (including those for prescription drugs);
- Charges that are not covered under the plan;
- Charges that exceed R&C limits; and
- Charges that exceed the maximum benefits for that year.
When a participant uses either a network or an out-of-network provider, his or her annual out-of-pocket maximum is $5,000 per participant, $10,000 per family.
Lifetime Maximum
The "lifetime maximum" is the maximum medical benefit payable for a covered participant throughout his/her lifetime. Once the lifetime benefit maximum is reached, no additional benefits will be paid.
The lifetime maximum benefit is $2 million per covered participant whether he or she sees network providers or out-of-network providers. The lifetime maximum benefit is combined for all self-insured medical plans offered by SAIC.
Please note: SAIC's self-insured plans do provide a $1,000 annual lifetime restoration, once the lifetime maximum is reached.
