2009 CONTRACT PROPOSAL

2009 CONTRACT PROPOSALMEDICAL PLAN DEDUCTIBLES/OUT‐OF‐POCKET SCENARIOS
The following scenarios assume that all claims will be in‐network, are for eligible services, and the dollar amounts referred to are theReasonable & Customary charges.Deductible: $350 single/$700 familyOOP Max: $1000 single/$3000 family
Scenario #1—single with medical claims for office visits & lab work totaling $2000Member must pay the first $350, which is the deductible. Now that the deductible is met, the member must pay 10% co‐insuranceof the remaining charge of $1650, which would be $165. Cost for member: $350 deductible + $165 out‐of‐pocket = $515.
Scenario #2—single with medical claims for major surgery & hospitalization totaling $40,000Member must pay the first $350, which is the deductible. Now that the deductible is met, the member must pay their 10% coinsuranceon only $10,000, which is $1000. This meets the requirement for the out‐of‐pocket maximum, and all remaining amountswill be covered by the company at 100%. Cost for member: $350 deductible + $1000 out‐of‐pocket = $1350.
Scenario #3—family of 2/child has surgery with bills totaling $12,000, and mom has office visits & lab work totaling $1500Child is the first one to incur medical expense—member is responsible for the first $350, which is the deductible. Now that theindividual deductible is met, the member must pay 10% co‐insurance only on $10,000(of the child’s bill), which is $1000. This meetsthe out‐of‐pocket max only on the child, and all remaining bills for child will be covered by the company at 100%. Because thefamily deductible & out‐of‐pocket max has not been met, mom must pay the first $350 of her expenses to meet the familydeductible, and then would be responsible to pay the 10% co‐insurance on $1150, which is $115. This family did not incur enoughexpense to reach the family out‐of‐pocket max. Cost to member: $700 deductible + $1115 out‐of‐pocket = $1815.
Scenario #4—family of 3/child has surgery totaling $12000, mom has office visits totaling $300, dad has office visits totaling $200Member is responsible for the first $350 of the child’s bill, which is the deductible. Now that the individual deductible has been met,the member must pay 10% co‐insurance only on $10000 (of the child’s bill), which is $1000. This meets the out‐of‐pocket max onlyon the child, and all remaining bills for the child will be covered by the company at 100%. Because the family deductible and out‐ofpocketmax has not been met, mom must pay her $300, which all applies to the deductible. Finally, $50 of dad’s charge will applyto the deductible, which meets the family deductible requirement. The remaining $150 bill would be reduced to the 10% coinsurance,for a payment of $15. This family did not incur enough expense to reach the family out‐of‐pocket max.Cost to member: $700 deductible + $1015 out‐of‐pocket = $1715.
Scenario #5—family of 4/dad has out‐patient surgery totaling $8000; child #1 has an ER visit totaling $3000;mom & child#2 both have office visits & lab work totaling $1500 eachDad must pay the first $350, which is his deductible. Now that his individual deductible has been met, he must pay 10% coinsuranceon the balance $7650, which is $765. This amount applies to the family out‐of‐pocket total. Child #1—member isresponsible to pay the first $350, which now meets the family deductible. Member must pay 10% co‐insurance on the balance$1650, which is $165. Since the deductible has now been met, the bills incurred for mom & child #2 will only require the 10% coinsurance,which is $150 for each one. This family did not incur enough expense to reach the family out‐of‐pocket max.Cost to member: $700 deductible + $1230 out‐of‐pocket = $1930.
Scenario #6—family of 4/all injured & hospitalized‐bills for each of the family members are $80000Member is responsible for $350 of the first family member’s expense, which is the deductible. Now that the individual deductible ismet, the member must pay 10% co‐insurance on only $10000, which is $1000. All remaining bills for this person will be covered bythe company at 100%. Member is also responsible for $350 of the 2nd family member’s expense, which now meets the familydeductible. Again, he/she must pay the 10% co‐insurance on only $10000, which is $1000. (Again the remaining balance covered bythe company at 100%.) Family member #3 now has no deductible, but member must pay 10% co‐insurance on only $10000, whichis $1000. (Remaining balance covered by the company at 100%.) The co‐insurance amount for the first 3 family members has nowtotaled $3000, which is the family out‐of‐pocket max. All bills for family member #4 will be covered by the company at 100%.Cost to member: $700 deductible + $3000 out of pocket = $3700.