Coverage Examples. This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self- only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Xxx’s Type 2 Diabetes (a year of routine in-network care of a well- controlled condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) ◼ The plan’s overall deductible $250 ◼ Primary care physician coinsurance 0% ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Primary care physician visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,700 In this example, Peg would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 10% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Specialist office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $5,600 In this example, Xxx would pay: ◼ The plan’s overall deductible $250 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 0% ◼ Other coinsurance 10% This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,800 In this example, Xxx would pay: Cost Sharing Deductibles $250 Copayments $10 Coinsurance $1,200 What isn’t covered Limits or exclusions $60 The total Peg would pay is $1,520 Cost Sharing Deductibles $250 Copayments $800 Coinsurance $70 What isn’t covered Limits or exclusions $20 The total Xxx would pay is $1,140 Cost Sharing Deductibles $250 Copayments $70 Coinsurance $100 What isn’t covered Limits or exclusions $0 The total Mia would pay is $420 Appendix "F" Delta Dental PPO (Point-of-Service) Summary of Dental Plan Benefits For Group# 7280 Towns...
Coverage Examples. These examples .show how '.this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans; m Amount owed to providers: $7,540 iii Plan pays $7,330 III Patient pays $210 Imll Amount c m PlanpaYl II Patient p
Coverage Examples. This is not a cost estimator. Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. Amount owed to providers: $5,400 Plan pays $4,120 Patient pays $1,280 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Note: These examples are based on individual coverage only. Deductibles $500 Copays $600 Coinsurance $100 Limits or exclusions $80 Total $1,280 Deductibles $700 Copays $20 Coinsurance $700 Limits or exclusions $200 Total $1,620 Patient pays: Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don’t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan. The patient’s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of- pocket expenses are based only on treating the condition in the example. The patient received all care from in- network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor’s advice, your age, how ...
Coverage Examples. These examples show how this plan might cover medical care in given situations. Use these examples to This is not a cost
Coverage Examples. These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost
