Deductibles are the fixed dollar amount that you must pay each year toward covered medical expenses before your medical option pays any benefit. Only reasonable and customary (R&C) expenses count towards your deductible.

The Core Option has no annual deductible for covered in-network services. The Core Option does have deductibles for out-of-network care that you must satisfy (pay) before your plan will pay any benefit: $250 for individual coverage, and a $500 family maximum.

The Traditional Option also has no annual deductible for covered in-network services. There is a deductible for out-of-network coverage, however, that must be satisfied before the plan pays any benefit: $400 for individual coverage and an $800 family maximum.

The Account-based Option has a high annual deductible that you must meet for both in-network and out-of-network services: $1,000 for individual coverage; $2,000 for family coverage. Remember: the annual deductible is significantly offset by the company funded Health Reimbursement Account (HRA) that McGraw-Hill provides for each Account-based Option participant, and the portion of the deductible that you pay is substantially lower.

If you stay in-network, office visits for preventive care are covered at 100% and the annual deductible does not apply. Out-of-network office visits and doctor visits for non-preventive care are subject to the annual deductible.

For individual coverage the annual deductible is $1,000. However, your primary deductible - that portion of the deductible you must meet first—is $250; your company-funded HRA pays the next $750, for a total annual deductible of $1,000.

For family coverage, the annual deductible is $2,000, but the primary deductible you must meet is $500; your company-funded HRA pays the other $1,500, for a total annual deductible of $2,000.

The Account-based Option offers you the opportunity to save for future healthcare expenses. Your HRA will pay for all covered expenses as long as there's a balance in the account. Any portion of your company funded HRA that you do not use during the year will be added to your HRA balance for the next year. Here's an example based on individual coverage.

Remember:

With the Core Option, there is no deductible in-network. When you go out-of-network, the maximum annual family deductible is $500. Remember, only charges within R&C will count toward your deductible. Any member of the family or combination of family members can meet the family deductible. For example, one member of the family can satisfy $200, another member $200, and a third member of the family can meet $100, for a total annual family deductible of $500. Or, one member can satisfy the $500 deductible alone. Remember, this is for out-of-network coverage only.

With the Traditional Option, there is no deductible in-network. When you go out-of-network, the maximum annual family deductible is $800. Remember, only charges within R&C will count toward your deductible. Any member of the family can meet the entire family deductible or all covered dependents can. For example, the covered employee sees an out-of-network specialist and the R&C charges are $300 for the office visit. You pay the full $300 for this visit (and any charges above R&C) and it is applied toward the family annual deductible. One of your covered dependents sees an out-of-network primary care physician (PCP) and the R&C charges are $250 for the office visit. The PCP recommends a special diagnostic test, which you choose to have as an outpatient at a non-network lab facility or hospital because it is closer to your home. R&C charges for the test are $250. You pay the full cost of the PCP visit and the diagnostic test and have now satisfied your annual family medical ($300 + $250 + $250 = $800). Or, one member can satisfy the $800 deductible alone.

Remember, you have the choice to see out-of-network providers, but you must fully satisfy the annual deductible before any benefits are reimbursed.

The Account-based Option works differently. The family deductible is the same for both in- and out-of-network coverage — $2,000. Remember, when you go out-of-network, only charges within R&C will count toward your deductible. The deductible is substantially offset by the company-funded Health Reimbursement Account (HRA). You pay the first $500 of eligible expenses and the HRA pays the next $1,500 of the annual deductible. Once the deductible is satisfied, benefits are reimbursed.

Any member of the family or combination of family members can meet the family deductible. For example, one member of the family can satisfy $200, another member $200, and a third member of the family can meet $100, for a total annual family deductible of $500. Once you meet the family deductible, the HRA will pay the next $1,500 of eligible expenses.

With the Account-based Option, preventive services are covered at 100% in-network and are not subject to the deductible.

Each medical option provides protection against unmanageable healthcare expenses in the event of a significant medical event by including an annual out-of-pocket maximum (OPM).

Out-of-pocket maximum means the most you can pay out of your own pocket for covered expenses per individual during the plan year. The OPM includes coinsurance but not deductibles, copays prescription drugs, or mental health/chemical dependency services.

For the Core Option and the Traditional Option, salary-based out-of-pocket maximums apply; for the Account-based Option, the OPM is a flat dollar amount, regardless of your salary. If you earn $30,000 a year, you will pay the same OPM as someone who earns $130,000 a year, so it's important that you fully understand how OPM's work.

The account based option has a fixed in-network and out-of-network annual out-of-pocket maximum; individual limits do not apply. All covered members' expenses can combine to meet the OPM.

The family OPM for a two-person family (employee + one other covered dependent) is $4,000 in-network, $8,000 out-of-network. The family OPM for Employee + 2 or more coverage is $6,000 in-network and $12,000 out-of-network. That means if you are an employee who covers yourself plus your spouse and three children (for a family of five), you pay a family OPM of $6,000 for in-network coverage and $12,000 for out-of-network coverage.

Reasonable and Customary (R&C) charges are the most a McGraw-Hill medical option will consider for reimbursement for covered out-of-network expenses. R&C charges are based on the range of fees charged by providers with comparable training and experience for the same or similar service in a particular geographic area. The medical option pays benefits based on the R&C charge for a covered service in a given area.

When you use in-network providers for your care under all three medical options, you pay for a percentage of services based on a negotiated rate for the services. If you choose to go out of the network for care under all three options, you will pay a higher percentage of the cost (at a negotiated rate) AND you are subject to reasonable and customary (R&C) charges. That means the medical option pays a percentage based on R&C charges and you will pay for any costs incurred over and above the negotiated rate.

R&C charges do not apply to in-network care.

Coinsurance is a percentage of the covered expenses you pay when you receive coverage for medical services or prescription drugs, after meeting any applicable annual deductible. Coinsurance applies to all three medical options as shown below.