Health Plan Comparisons with Scenarios

How Your Medical Plans Work

• Eva notices a changing sunspot and sees an in-network dermatologist
• Services: specialist exam, in-office biopsy, pathology
• Plan status: Eva has not yet met her in-network deductible for the year
• Individual deductible (embedded): $2,500
• Coinsurance after deductible: member 30% / plan 70%
• Out-of-pocket max (individual): $5,000
• Generic topical Rx copay: $0

What the employee can expect to pay under the Core PPO Plan:

• Eva’s dermatology visit total allowed charges: $1,600
• Since Eva has not met her $2,500 deductible, she pays the full $1,600 applied to the deductible
• Remaining deductible after visit: $900
• Coinsurance does not apply yet
• If prescribed a generic topical, pharmacy copay is $0
• Total out-of-pocket for this visit: $1,600

What the employee can expect to pay under the Buy-Up PPO Plan:

• If Eva had the Buy-Up PPO and the same $1,600 allowed charges:
• She would pay a $50 specialist copay
• Since Eva has not met her $400 deductible, she pays the full $400 applied to the deductible
• Then pay 20% coinsurance on the remaining $1,200 = $240.
• Total estimated out-of-pocket: $50 + $400 + $240 = $690

Copays count toward your out-of-pocket maximum, or the annual limit on what you’ll pay.
Copays do not count toward your deductible.

• Michael falls off his bike and goes to the Emergency Department with a painful, swollen ankle
• ED care includes evaluation, X-rays, splinting
• Allowed (in-network) total for ED visit, imaging and treatment (example): $8,000

What the employee can expect to pay under the Core PPO Plan:

• Michael’s ED visit total allowed charges: $8,000
• Since deductible is $2,500 and not met, he would pay the first $2,500 applied to deductible
• Remaining allowed charges: $8,000 - $2,500 = $5,500
• Then pay 30% coinsurance on $5,500 = $1,650
• Total estimated out-of-pocket: $2,500 + $1,650 = $4,150 (capped at $5,000 OOP max)

What the employee can expect to pay under the Buy-Up PPO Plan:

• If Michael had the Buy-Up PPO and the same $8,000 allowed charges for the ED visit:
• At registration, Michael pays a $500 ED copay
• Total out-of-pocket for this event: $500

• 3-year-old child develops ear pain, fever, irritability one evening and is diagnosed with an ear infection the same day at an urgent care clinic
• Urgent care visit includes 1 generic antibiotic prescription
• Allowed (in-network) total for urgent care visit: $200

What the employee can expect to pay under the Core PPO Plan:

• Michaela’s urgent care visit total allowed charges: $200
• Michaela’s parents would pay a $75 urgent care copay
• The generic prescription will be covered in full
• Total estimated out-of-pocket: $75

What the employee can expect to pay under the Buy-Up PPO Plan:

• If Michaela had the Buy-Up PPO and the same $200 allowed charges for the urgent care visit:
• Michaela’s parents would pay a $75 urgent care copay
• The generic prescription will be covered in full
• Total out-of-pocket for this event: $75

What the employee can expect to pay at the Employee Health & Wellness Center:

▪ No cost to employee

Disclaimer

The information in this presentation was taken from various summary plan descriptions and benefit information. This summary of benefits is not a legal plan document and does not imply a guarantee of employment or a continuation of benefits. Full details of the plans are contained in the Summary Plan Descriptions (SPDs), which govern each plan’s operation. Whenever an interpretation of a plan benefit is necessary, the actual plan documents will prevail. Carrier contracts are the final benefit determinant. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about your benefits, please contact HR.