2021 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 34
You must pay for a certain portion of the cost of Covered Expenses under the Medical Plan, including (as applicable)
any Copay, Deductible and Coinsurance percentage that is not paid by the Medical Plan, up to the Out-of-Pocket
Maximum set by the Medical Plan.
Coinsurance is the percentage of eligible expenses the Medical Plan and the Covered Person are required to pay.
The amount of Coinsurance a Covered Person is required to pay is the difference from what the Medical Plan pays
as shown in the Medical Schedule of Benefits.
There may be differences in the Coinsurance percentage payable by the Medical Plan depending upon whether
you are using a Participating Provider or a Non-Participating Provider. These payment levels are also shown in the
Medical Schedule of Benefits.
A Copay is the portion of the medical expense that is your responsibility, as shown in the Medical Schedule of
Benefits. A Copay is applied for each occurrence of such covered medical service and is not applied toward
satisfaction of the Deductible, Coinsurance or Out-of-Pocket Maximum.
NOTE: This section only applies to medical benefits under the Group Medical Plan. Please refer to the
Dental and Vision Plan included in the Group Health Plan for the Deductible, if any, applicable to those
A Deductible is the total amount of eligible expenses as shown in the Medical Schedule of Benefits, which must
be Incurred by you during any Calendar Year before Covered Expenses are payable under the Medical Plan. The
family Deductible maximum, as shown in the Medical Schedule of Benefits, is the number of deductibles which
must be Incurred by the covered family members during a Calendar Year. However, each individual in a family is
not required to contribute more than one individual Deductible amount to a family Deductible.
If the Deductible is satisfied in whole or in part by eligible expenses Incurred during October, November or
December, those expenses will apply to the Deductible applicable in the next Calendar Year.
If 2 or more covered family members suffer Injuries from the same Accident, only one Deductible will be applied to
all charges Incurred for the treatment of those Injuries during the Calendar Year.
An Out-of-Pocket Maximum is the maximum amount you and/or all of your family members will pay for eligible
expenses Incurred during a Calendar Year before the percentage payable under the Medical Plan increases to
The single Out-of-Pocket Maximum applies to a Covered Person with single coverage. When a Covered Person
reaches his or her Out-of-Pocket Maximum, the Medical Plan will pay 100% of additional eligible expenses for that
individual during the remainder of that Calendar Year.
The family Out-of-Pocket Maximum applies collectively to all Covered Persons in the same family. The family Outof-Pocket Maximum, if applicable, is the maximum amount that must be satisfied by covered family members during
a Calendar Year. The entire family Out-of-Pocket Maximum must be satisfied; however, when an individual in a
family meets the Out-of-Pocket amount for single coverage, the amount applies towards the family Out-of-Pocket
Maximum. The Medical Plan will pay 100% of Covered Expenses for any Covered Person in the family during the
remainder of that Calendar Year.
Your Out-of-Pocket Maximum may be higher for Non-Participating Providers than for Participating Providers.
Please note, however, that not all Covered Expenses are eligible to accumulate toward your Out-of-Pocket
Maximum. The types of expenses, which are not eligible to accumulate toward your Out-of-Pocket Maximum, (“nonaccumulating expenses”) include: