Sample cost sharing:
sample coverage
examples below
3
For the examples below, this sample
cost-sharing information is used:
$50
Coinsurance
What you pay will be different, depending on the care you need, if you get
in-network care, what your doctor and other providers charge and other factors.
Emergency room
in-network visit
$0
Copayment
Do not use these examples below to estimate what you will pay.
Annual deductible for in-network services received $1,000
Copayment for doctor visit
$50
In-network doctor visit
(managing diabetes)
Deductible left to meet
These three examples show you how health insurance covers the costs of your medical
care and how deductibles, copayments and coinsurance impact what you will pay.
Not applicable
Copayment for emergency room visit
Coinsurance (your plan pays)
(you pay)
Having a baby
Deductible left to meet
$500
Deductible left to meet
Copayment
$500
Copayment
Coinsurance
$500
80%
20%
Not applicable
$1,000
Not applicable
Coinsurance (your plan pays)
80%
Sample billed amount
$500
Sample billed amount
$5,000
Sample billed amount
$30,000
Sample allowed amount
$200
Sample allowed amount
$2,500
Sample allowed amount
$20,000
(doctor’s agreement with health
plan to accept lower amount)
Calculating your sample out-of-pocket costs
Sample allowed amount $200
(provider’s agreement with
health plan to accept lower amount)
Calculating your sample out-of-pocket costs
(provider’s agreement with
health plan to accept lower amount)
Calculating your sample out-of-pocket costs
Sample allowed amount $2,500
Sample allowed amount $20,000
– $0
Deductible left to meet – $500
Deductible left to meet – $1,000
Copayment – $50
Copayment – $500
Deductible left to meet
Coinsurance
– $0
Coinsurance
In this sample, you pay
$50
In this sample, you pay $1,000
In this sample, your plan pays $150
In this sample, your plan pays $1,500
For definitions of common terms, see the Glossary at www.[insert].com or
Call 1-800-[insert] to request a copy.
– $0
Copayment
– $0
Coinsurance (you pay 20%) – $3,800
In this sample, you pay
$4,800
In this sample, your plan pays $15,200
Sample cost sharing:
sample coverage
examples below
3
For the examples below, this sample
cost-sharing information is used:
$50
Coinsurance
What you pay will be different, depending on the care you need, if you get
in-network care, what your doctor and other providers charge and other factors.
Emergency room
in-network visit
$0
Copayment
Do not use these examples below to estimate what you will pay.
Annual deductible for in-network services received $1,000
Copayment for doctor visit
$50
In-network doctor visit
(managing diabetes)
Deductible left to meet
These three examples show you how health insurance covers the costs of your medical
care and how deductibles, copayments and coinsurance impact what you will pay.
Not applicable
Copayment for emergency room visit
Coinsurance (your plan pays)
(you pay)
Having a baby
Deductible left to meet
$500
Deductible left to meet
Copayment
$500
Copayment
Coinsurance
$500
80%
20%
Not applicable
$1,000
Not applicable
Coinsurance (your plan pays)
80%
Sample billed amount
$500
Sample billed amount
$5,000
Sample billed amount
$30,000
Sample allowed amount
$200
Sample allowed amount
$2,500
Sample allowed amount
$20,000
(doctor’s agreement with health
plan to accept lower amount)
Calculating your sample out-of-pocket costs
Sample allowed amount $200
(provider’s agreement with
health plan to accept lower amount)
Calculating your sample out-of-pocket costs
(provider’s agreement with
health plan to accept lower amount)
Calculating your sample out-of-pocket costs
Sample allowed amount $2,500
Sample allowed amount $20,000
– $0
Deductible left to meet – $500
Deductible left to meet – $1,000
Copayment – $50
Copayment – $500
Deductible left to meet
Coinsurance
– $0
Coinsurance
In this sample, you may pay
$50
In this sample, you may pay $1,000
In this sample, your plan may pay $150
In this sample, your plan may pay $1,500
For definitions of common terms, see the Glossary at www.[insert].com or
Call 1-800-[insert] to request a copy.
– $0
Copayment
– $0
Coinsurance (you pay 20%) – $3,800
In this sample, you may pay
$4,800
In this sample, your plan may pay $15,200