Schedule of Medical Benefits - Cost
Medical Plan Costs
Applies to all services, unless
otherwise noted or copayment is
(% of allowed charges member pays)
|Annual Out-of-Pocket Maximums
(Out-of-Pocket Maximum paid in a benefit year)
|Managed Care ONLY -
Copayment (on outpatient visits)
*Services from an out-of-network provider have a 35% coinsurance on any plan. In addition, there is a separate deductible and an annual coinsurance maximum on Managed Care Plans. An out-of-network provider can balance bill the difference between the allowance and the charge.
A percentage of allowable and covered charges that a member is responsible for paying, after paying any applicable deductible. The medical plan pays the remaining allowable charges. For example, in the above diagram if Jane has met her deductible for the Traditional Plan In-Network medical costs ($1,000), she pays 25% of additional allowable costs and the plan pays 75% of allowable charges.
- Coinsurance Maximum
The maximum dollar amount of any coinsurance that a member or family must pay in a plan year. Once the coinsurance maximum has been paid, the member or family is not responsible for paying any further allowable charges for the remainder of the benefit year. The coinsurance maximum applies to the plan year July 1 through June 30, regardless of hire date. For example, in the above diagram Jane has met her coinsurance maximum of $5,000 in the Traditional Plan so the plan pays 100% of allowable charges for any additional expenses.
A fixed dollar amount for allowable and covered charges that a member is responsible for paying. The medical plan pays the remaining allowable charges. This type of cost-sharing method is typically used by managed care medical plans.
A set dollar amount that a member and family must pay before the medical plan begins to share the costs. The deductible applies to the plan July 1 through June 30. For example, Jane’s deductible under the Traditional plan is $1,000. Her plan won’t pay anything until she has met her deductible.
- In-Network Providers
Providers who contract with a plan to manage the delivery of care for plan members.
- Out-of-Network Provider
Any provider who renders services to a member but is not a participant in the plan’s network.