Health Plan Examples
Example 1: Chris enrolled for single coverage. He pays 100% of all his prescription drug charges until he meets his $2600 annual deductible. Once the deductible has been met, he begins to pay either co-pays or co-insurance for his medications ($5 tier 1, $35 tier 2, and $70 tier three and 20% co-insurance for tier 4 specialty medications). Chris has an emergency room visit with total charges of $1,500. Because Chris has met the deductible he must now pay 20% coinsurance, $1,500 x 20% is $300.
Once Chris’s prescription drug co-pays and coinsurance for medical services reach $2,600 in out-of-pocket cost, the Plan will then pay 100% of his prescription and in-network medical for the remainder of the calendar year. In this example, Chris’s total OPM is $5200. Chris uses the money in his HSA to pay for his out of pocket medical and prescription drug expenses.
Example 2: David is enrolled for family coverage. On January 2, he has an emergency appendectomy at Claxton Hepburn Hospital (an in-network provider). The hospital charge is $12,000. David pays the first $5,200 for a deductible and then 20% coinsurance on the remainder; 12,000 - 5,200 is 6,800 x 20% is $1360. David pays $6560 (5,200+1360) total and the plan pays $5440. For the remainder of the year, David and his family will pay 20% of in-network medical expenses and prescription copays of $5/35/70/20%. If David and his family’s out-of-pocket expenses reach $10,400, all in-network medical and pharmacy expenses will be covered by the plan. David uses the money in is HSA to pay for medical and prescription drug expenses incurred by he and his family.
Example 1: Jennifer is enrolled for family coverage. Jennifer is scheduled for outpatient surgery in January at CPH (an in-network provider). The hospital charge will be $9,000 for the procedure. Jennifer pays the first $500 for a deductible. Jennifer also pays 20% of the remaining charge; $8,500 x 20% is $1,700 coinsurance. Because $500 + $1,700 exceeds the OPM, Jennifer pays just $1,750 and the plan pays $7,250. Additionally, the plan will pay 100% of the in-network medical charges for the remainder of the calendar year as Jennifer has met her OPM for the plan year after paying the hospital bill. Once Jennifer and two more members of her family each reach the OPM, the plan will pay 100% of medical expenses for the entire family.