Examples of How Medical Plan Charges Work in 2021
Below are some examples of how the medical plan works in different situations.
Visiting an In-Network Provider
Kerri Lyon sees her primary care physician (PCP) for a medical condition. Kerri will pay her $20 copay. There is no coinsurance or a deductible for in-network provider visits.
|
Allowable charge for the visit: |
$155 |
|
Minus Kerri’s copay: |
$20 |
|
Equals a remaining balance of: |
$135 |
|
Kerri’s cost for the visit (copay only): |
$20 |
Visiting an Out-of-Network Provider before Meeting the Deductible
Kerri chooses to see an out-of-network provider for a medical condition. Kerri has not yet satisfied her annual deductible ($1,000/Individual, $2,000/Family). Kerri will pay her annual deductible of $1,000 and 50 percent coinsurance.
|
Allowable charge for the visit: |
$2,000 |
|
Kerri’s deductible: |
$1,200 |
|
Equals a remaining balance of: |
$800 |
|
Kerri’s coinsurance is 50 percent of the remaining balance: |
$400 |
|
Kerri’s cost for the visit (deductible plus coinsurance): |
$1,600 |
Visiting an Out-of-Network Provider after Meeting the Deductible
Kerri chooses to see an out-of-network physician for a medical condition. Kerri has met her annual deductible and will be responsible for 50 percent coinsurance.
|
Allowable charge for the visit: |
$150 |
|
Kerri’s deductible: |
Kerri has already satisfied the annual deductible |
|
Kerri’s coinsurance is 50 percent of the visit: |
$75 |
|
Kerri’s cost for the visit (coinsurance): |
$75 |
Outpatient Surgery at a Level A Facility before Meeting the Deductible
Kerri has not fulfilled her annual deductible. Kerri sees a specialist, and he advises she will need outpatient surgery. Kerri’s surgeon schedules the surgery at a Carilion Clinic facility, which is a Level A facility. Kerri will pay her annual deductible of $600, her outpatient surgery copay of $500 and 20 percent coinsurance of the remaining balance.
|
Allowable charge for the facility visit: |
$2,000 |
|
Kerri’s deductible: |
$800 |
|
Kerri’s copay: |
$500 |
|
Equals remaining balance of: |
$700 |
|
Kerri’s coinsurance is 20 percent of the remaining balance: |
$140 |
|
Kerri’s cost for the visit (deductible plus copay plus coinsurance): |
$1,440 |
Outpatient Surgery at a Level A Facility after Meeting the Deductible
Kerri fulfilled her deductible with a prior service. Kerri is scheduled for outpatient surgery at a Carilion Clinic facility, which is a Level A facility. Kerri will be responsible for her outpatient surgery copay of $500 and 20 percent coinsurance.
|
Allowable charge for the facility visit: |
$2,000 |
|
Kerri’s deductible: |
Kerri already satisfied the annual deductible |
|
Kerri’s copay: |
$500 |
|
Equals a remaining balance of: |
$1500 |
|
Kerri’s coinsurance is 20 percent of the remaining balance: |
$300 |
|
Kerri’s cost for the visit (copay plus coinsurance): |
$800 |
Outpatient Surgery at a Level B Facility before Meeting the Deductible
Kerri has not satisfied her annual deductible ($800/individual, $1,600/Family). Kerri sees a specialist, and he advises she will need outpatient surgery. Kerri chooses to have the surgery at a Level B facility. Kerri will be responsible for her annual deductible of $800, her outpatient surgery copay of $750 and 40 percent coinsurance of the remaining balance.
|
Allowable charge for the facility visit: |
$2,000 |
|
Kerri’s deductible: |
$1,000 |
|
Kerri’s copay: |
$750 |
|
Equals a remaining balance of: |
$250 |
|
Kerri’s coinsurance is 40 percent of the remaining balance: |
$100 |
|
Kerri’s cost for the visit (deductible plus copay plus coinsurance): |
$1,850 |
Outpatient Surgery at a Level B Facility after Meeting the Deductible
Kerri satisfied her annual facility deductible when she previously used a Level B facility for another outpatient surgery. Kerri chooses to have the outpatient surgery at a Level B facility. Kerri will be responsible for her outpatient surgery copay of $750 and 40 percent coinsurance.
|
Allowable charge for the facility visit: |
$2,000 |
|
Kerri’s deductible: |
Kerri has already satisfied the annual deductible |
|
Kerri’s copay: |
$750 |
|
Equals a remaining balance of: |
$1,250 |
|
Kerri’s coinsurance is 40 percent of the remaining balance: |
$500 |
|
Kerri’s cost for the visit (copay plus coinsurance): |
$1,250 |
Inpatient Surgery at a Level A Facility before Meeting the Deductible
Kerri is admitted to a Carilion Clinic facility, which is a Level A facility, for a three day stay. Kerri has not fulfilled her annual facility deductible. Kerri will be responsible for her annual deductible of $600 and 20 percent coinsurance.
|
Allowable charge for the facility visit: |
$20,000 |
|
Kerri’s deductible: |
$800 |
|
Equals a remaining balance of: |
$19,200 |
|
Kerri’s coinsurance is 20 percent of the remaining balance, up to the $4,000 Level A Out-of-pocket maximum: |
$3,840 |
|
Kerri’s cost for the visit (copay plus coinsurance): |
$4,000 |
Once Kerri has reached the out-of-pocket maximum, any charges for provider visits, prescriptions at Level A pharmacies and services at Level A facilities will be covered at 100 percent for the remainder of the calendar year.
A Note about Out-Of-Pocket Maximums
Any money you pay toward deductible, copays or coinsurance is applied to the out-of-pocket maximum. When you have met your individual or family out-of-pocket maximum, your medical charges will be covered at 100 percent for the remainder of the calendar year.
