Deductible

[Guest SHELLEY CINTRON]

:eek:

We have a self-funded Indemnity plan, the plan has a $100.00 individual deductible, $200.00 family deductible, then plan will pay 80% within UCR. Correct me if I am wrong. An employee has not incurred any medical expenses this year as of yet, but his dependents have (so far $195.00). The employee says that the plan should have paid the claims after the $100.00 was met. I told him and my benefits coordinator that the claims were processed accurately. Because the $200.00 must be met before the plan will pay the claim. They are saying that the employee's deductible has nothing to do with the family's deductible. I said not so, because again the plan has a $200.00 deductible. When the $200.00 has been met then we will pay any claims, and the employee does not have meet his $100.00 because his dependents have met the $200.00 with their claims. Is there anywhere or anything I can put my hands on to show them that a family includes the employee and the dependents. Thanks.

[KIP KRAUS]

Even though you have a self-insured medical plan the deductibles typically work as individual and family deductibles. If the individual deductible is $100 then any person in the family that meets the $100 is entitled to payment after meeting the individual deductible. If one of the employee’s dependents had expenses of $195 then the $95 would be payable at 80%, but you said dependents had $195. How much was met by each?

The family deductible of course applies to dependents, if it didn’t what reason would there be for a family deductible? A family does not have to meet the family deductible before any one in the family gets reimbursement.

Some plans allow a combination of family members to meet the family deductible. In your pan’s case for instance if three family members have deductible amounts of $80, $100, and $20 then the family deductible would be met and no other family member would have to meet a deductible.

On the other hand, some plans require two or more family member to meet the total individual deductible before the family deductible is met. So in the case of your plan two family members would have to meet the $100 deductible before the family deductible is met.

[mroberts]

What Kip is basically saying is it depends on how your plan is written. Check out your company's SPD and look under deductible and see how an employee or dependent can meet the requirement of satisfying it.