Frequently Asked Questions - Maximum Out-of-Pocket & Deductibles

What is a "maximum out-of-pocket limit" or "MOOP"?
The most you'll have to pay for covered healthcare services in a plan year. Once you reach the MOOP limit, the plan pays 100% of your covered healthcare services for the rest of the year.

  • For the CDHP options, this amount includes prescription drug costs. 
  • For the traditional plan options (PPO and EPO), prescription drug costs do not count toward the plan's MOOP limit.
  • However, there is also a federal MOOP limit that applies to both medical and prescription drug costs. Once the federal MOOP limit is met, the plan will pay 100% of your covered healthcare services for the rest of the year, no matter which plan option you're enrolled in.
     

Do deductibles apply to MOOP?
Yes, the amount the employee pays for covered medical expenses that apply to the deductible also apply to the MOOP.


Do out-of-network costs apply to the MOOP? 
No. Neither out-of-network penalties nor any amount over Usual & Customary apply to your MOOP.


Do services which aren't covered by the plan apply to the MOOP?

No. This is for covered healthcare services only.


Do I have to meet my deductible before I can be eligible for co-insurance?

Yes. For example, if you are charged $200 for a healthcare service and you have not met your deductible, you will have to pay the full $200. Any amount applied to your deductible will also be applied to your MOOP.


How often do you need to meet the deductible? Every year? Every procedure?
Deductibles renew every calendar year. The deductible only needs to be met once per calendar year.


Can one member of a family satisfy the family deductible?
For the traditional plan options (PPO and EPO), it takes two or more people to satisfy the family deductible. The family deductible is met when two or more people have incurred eligible expenses that meet their individual deductibles in a calendar year. 

For the CDHP options, one person can meet the entire family deductible, or it can be met through multiple family members.


Are there any medical costs that won't go toward meeting the deductible? 
There are out of pocket medical expenses that won't go toward the deductible. For example, prescription drug co-pays and emergency room fees don't go toward the deductible. Routine vision and dental expenses also don't apply to the medical plan deductible. Any preventive procedure where the company pays 100% is not credited toward the employee's deductible. Also, any services not covered by the Caterpillar healthcare plan cannot go toward the deductible (i.e. Lasik surgery).