Covered California Certified Enroller Practice Exam

How do both the prescription deductible and medical deductible affect member costs in a plan year?

1. They do not contribute to the out-of-pocket maximum

2. Both deductibles apply to the out-of-pocket maximum

3. Only the highest deductible applies

4. They are waived for chronic conditions

The correct answer is: Both deductibles apply to the out-of-pocket maximum

The correct choice highlights that both the prescription deductible and the medical deductible contribute to the overall out-of-pocket maximum for the member. When members enroll in a health plan, they face different types of deductibles — one for medical services and another for prescription medications. Contributing to the out-of-pocket maximum means that when members pay for medical services and prescriptions, the amounts they pay towards those deductibles are counted towards their maximum limit. This is crucial because it provides financial protection; once the member reaches their out-of-pocket maximum, they do not have to pay for most covered services or prescriptions for the rest of the year. This understanding is significant for both enrollers and members because it affects how individuals budget for healthcare costs throughout the year. It ensures that both deductibles work together to provide a clearer picture of the total financial responsibility that a member may face, ultimately assisting them in making informed choices about their healthcare coverage.