Maximum Annual Out-of-Pocket Limit. A
Covered Individual shall not be required to pay in-network
Covered Charges exceeding $1,500 per calendar year. Once a
Covered Individual has paid $1,500 of out-of-pocket
Covered Charges in a calendar year, the Plan will pay the balance of
Covered Charges incurred during the remainder of the calendar year at 100% for in-network services and at 80% for out-of-network services. In no event will the out-of-pocket
Covered Charges exceed the maximum amount allowable under the Affordable Care Act, which for 2015 is
$13,200 per family ($6,600 single).
Special Rules for Out-of-Network Emergency Care. If you experience a medical
condition with acute symptoms (including severe pain) such that you require emergency
care to address a serious threat to your (or your unborn child's) health and/or the
functioning of an organ or other part of your body, you may seek emergency care without
prior authorization and without regard to whether the emergency care provider (e.g., a
hospital) is in-network or out-of-network. The
Plan will cover the charges of an out-of-network
emergency care provider at least to the extent of the greatest of (i) what the
Plan negotiated for the services with in-network providers (excluding any in-network copayment
or co-insurance imposed on the
Participant or
Dependent), (ii) the provider's
Reasonable and Customary Charges minus any co-pays and co-insurance that would have
applied to an in-network provider, and (iii) the amount that would be paid by
Medicare minus any co-pays and co-insurance that would have applied to an in-network provider.
The preceding sentence will be applied in accordance with 45 C.F.R. §147.138(b).