Enrollee, or provider of services, or if coverage was obtained based on inaccurate, false, or misleading information provided on the enrollment application, or for nonpayment of premiums. III. Financial Responsibilities A. Premium. The Subscriber is liable for payment to the Group of their contribution toward the monthly premium, if any. B. Financial Responsibilities for Covered Services. Note: Various Cost Shares may or may not be eligible for determining the Enrollee’s annual Health Savings Account contribution limit. Please contact the Health Savings Account trustee or administrator regarding questions about requirements for Health Savings Accounts. The Subscriber is liable for payment of the following Cost Shares for Covered Services provided to the Subscriber and their Dependents. Payment of an amount billed must be received within 30 days of the billing date. Charges will be for the lesser of the Cost Shares for the Covered Service or the actual charge for that service. Cost Shares will not exceed the actual charge for that service. 1. Annual Deductible. Note: Covered Services may be subject to an annual Deductible. The annual Deductible amount an Enrollee must pay is determined by whether the Enrollee is a sole Subscriber or has enrolled Dependents. Subscriber Only Coverage (individual coverage). Charges subject to the annual Deductible shall be borne by the Subscriber during each calendar year until the annual Deductible is met. Family Coverage (coverage for the Subscriber plus one (1) or more Dependents). Charges subject to the annual Deductible shall be borne by the Subscriber during each calendar year until the total family annual Deductible is met. The total family annual Deductible can be met by one member or by all family members in combination. Until the total family annual Deductible is met, benefits will not be provided for any family member. 2. Plan Coinsurance. After the applicable annual Deductible is satisfied, Enrollees may be required to pay Plan Coinsurance for Covered Services. 3. Copayments. Enrollees shall be required to pay applicable Copayments at the time of service. Payment of a Copayment does not exclude the possibility of an additional billing if the service is determined to be a non-Covered Service or if other Cost Shares apply. 4. Out-of-pocket Limit. Note: The Enrollee’s Out-of-pocket Limit is determined by whether the Enrollee is a sole Subscriber or has enrolled Dependents. Out-of-pocket Expenses which apply toward the Out-of-pocket Limit are set forth in Section IV. Total Out- of-pocket Expenses incurred during the same calendar year shall not exceed the Out-of-pocket Limit. C. Financial Responsibilities for Non-Covered Services. The cost of non-Covered Services and supplies is the responsibility of the Enrollee. The Subscriber is liable for payment of any fees charged for non-Covered Services provided to the Subscriber and their Dependents at the time of service. Payment of an amount billed must be received within 30 days of the billing date. PEBB HMOHSA 2024 11