Understanding Your Deductible

What is a deductible?
The deductible is a specified dollar amount you must pay for covered services before your health plan begins to pay for benefits.  You may be required to pay any applicable deductible at the time you receive service from a provider.

What is the amount of your deductible in the County’s Standard PPO?

• If you stay within the Highmark PPO network, your ANNUAL INDIVIDUAL deductible is $200.  Your ANNUAL FAMILY deductible is $400.
• If you go outside the Highmark PPO network, your ANNUAL INDIVIDUAL deductible is $4,500 and your ANNUAL FAMILY deductible is $13,500.

What Services apply toward the deductible?
Services such as hospital expenses, medical/surgical expenses, diagnostic services, durable medical equipment, skilled nursing care and home health care will apply toward your deductible.  Please  contact Highmark Member Services if you have questions as this is not a complete list.

What Services do not apply toward the deductible?
Services such as routine annual physicals, well baby visits and routine annual mammograms do not apply to your deductible.  Applicable copayments will apply for these visits.  Actual copayments do not apply toward your deductible.

How is the family deductible reached?
The family deductible can be reached a few different ways.  It is important to know that one member is not responsible for meeting the family deductible alone.  Once one member reaches the $200 in-network deductible, his/her eligible services will be covered at 100% (not including copayments).  Other family members with services incurred will have to make up the remaining $200 of the family deductible in order for their eligible services to be covered at 100%.  Other sample scenarios are as follows:

• Two family members reach their individual plan year deductibles – any remaining eligible services for these family members and any other covered dependents will be covered at 100% since two family members collectively met the $400 annual deductible.
• Multiple family members can incur expenses that collectively total the family deductible of $400 (i.e. each member of a family of four incurs $100 worth of services that are applied to the family deductible).  No one member has to reach the $200 individual deductible maximum for eligible expenses to be covered at 100% since the family deductible was met collectively by all four members.

What is covered when I go to my doctor for a sick visit?
When you go to the doctor because you are ill, you will be responsible for the $20 copayment at the time you go to the doctor (just like now).  If your doctor orders any sort of x-ray or lab work, you will be responsible for those charges since those are outside of the office visit consult with your doctor.  You will typically be billed for these services a couple weeks after the date of service.

How do I know what to pay?
You will receive an Explanation of Benefits (EOB) from Highmark for any services you and your covered family members have rendered.  The EOB will show what the provider charged, what Highmark’s discounted negotiated fee is for that service (if applicable) and how much Highmark paid (remember Highmark typically does not pay until your deductible is met unless the service is routine in nature).  The EOB will indicate an amount that you will owe. 

You will also receive an invoice from your provider.  The statement should have the same figures on it as the EOB.  You should see that the discounts were applied (if applicable).  If the invoice from your provider and the EOB match, you can go ahead and pay your provider.  If they do not, contact customer service at Highmark – the number is on the back of your Highmark ID card.