The Standard PPO Plan uses an embedded deductible, which means:

• In-Network Individual deductible of $1,000
• In-Network Family deductible of $3,000
• Family coverage is (employee + one adult, employee + child(ren), or employee + one adult and children). If member A reached $1,000 in claims, they would then only be responsible for coinsurance going forward for member A's claims. If they also cover a spouse, the spouse would still pay the full amount until the spouse also reaches the $1,000 deductible. The only time an individual would not have to reach their entire $1,000 individual deductible would be if the family deductible of $3,000 is met by other members of the family.
• If enrolled in single coverage (employee only), once the employee reaches their individual deductible ($1,000), the plan starts paying 80%.

The High Deductible PPO Plan uses an aggregate deductible, which means:

• In-Network Individual deductible of $1,850
• In-Network Family deductible of $3,700
• If enrolled in family coverage (employee + one adult, or employee + child(ren), or employee + one adult and children), everyone in the family contributes to the family deductible ($3,700), and that deductible must be met before the plan starts paying 80%.
• If enrolled in single coverage (employee only), once the employee reaches their individual deductible ($1,850), the plan starts paying 80%.

In-Network:

With an in-network provider, the PPO discount will first be deducted from the total billed charges. 

For some services under the Standard PPO Plan (such as a doctor’s office visit), you will pay a copay. There are no office visit co-pays under the High Deductible PPO Plan.

Wellness benefits are covered at 100% with an in-network UHC PPO provider under both the Standard and High Deductible PPO Plans.

You will get the best benefit by visiting an in-network provider. 

Out-of-Network:

When you use an out-of-network provider, there are no PPO discounts. An out-of-network provider can charge any amount they choose for their services except under certain situations, such as emergency care.

For this reason, it is not recommended that you use an out-of-network provider for non-emergency services unless you are fully aware of the cost of services in advance.

UMR will determine a “Maximum Allowable Charge” (MAC) amount for services an out-of-network provider provides. 

After your deductible is met, UMR will pay 60% of the Maximum Allowable Charge (MAC) amount for the out-of-network provider’s services, and you will owe 40% of MAC (your co-insurance), plus any balance billing! 

Example:

• An out-of-network surgeon charges $20,000 for an elective (non-emergency) surgical procedure.
• UMR determines that the MAC for the surgery is $10,000.
• The plan pays 60% of The $10,000 MAC or $6,000.
• You would owe 40% of MAC or $4,000 plus the $10,000 difference between the $10,000 MAC amount and the $20,000 total fee the out-of-network provider charges.

In the example above, UMR would pay $6,000, and you would owe a total of $14,000.