Hybrid Plan Example

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.