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Deductibles & out-of-pocket maximums

What is a deductible?

A deductible is a fixed amount a member must pay during a given time period, usually within a calendar year, before their health insurance benefits begin to cover the costs of their care.

Do we have deductibles in the GHI CBP plan and will our deductibles change under the NYCE PPO plan?

For in-network care, there is no deductible in the GHI CBP plan with the exception of durable medical equipment (which has a $100 deductible, which is reimbursed by the UFT Welfare Fund-eligible members). That will not change in the new plan.

For out-of-network care, there is a $200 deductible in the GHI CBP plan for individuals and $500 deductible for families. That deductible will also remain the same in the new plan.

Will the out-of-pocket maximum change in the NYCE PPO plan?

The total out-of-pocket maximum will not change. Because EmblemHealth/UnitedHealthcare will provide both medical and hospital coverage, there will now be one in-network out-of-pocket maximum, instead of it being split into two like the current bifurcated plan. This maximum for both medical and hospital coverage will remain a total of $7,150 for individuals and $14,300 for families.

Out of network:

In both the GHI CBP plan and the new plan, there is no out-of-pocket maximum for out-of-network services.

In-network:

Under the NYCE PPO plan, the total out-of-pocket maximum will remain the same, but the hospital and doctor deductibles will be combined.

How does the out-of-pocket maximum affect me?

The out-of-pocket maximum affects less than .01% of all people in the plan each year. For example, in 2024, of the 750,000 people enrolled in the GHI CBP plan, only 35 of them reached the hospital maximum and only 29 reached the doctor maximum.

What other protections does the NYCE PPO Plan offer?

The new plan continues to include several built-in protections for specialty services:

  • Hospital and skilled nursing stays are capped at $300 per stay, with a combined annual cap of $750.
  • Dialysis copays are capped at $200 per year.