Health Plan Cost Comparisons

Examples of 2013 Health Insurance Costs: Riverside CareAdvantage PPO and Anthem HealthKeepers HMO 25/30

Please note that all costs are examples to illustrate differences between plans and not actual costs. Your out-of-pockets may differ depending on the services you receive.

John and Jane are married and they have a son, Joe, and a daughter, Jill. Below are examples of what some health care services might cost under the Riverside CareAdvantage PPO and the Anthem HealthKeepers HMO 25/30.

Covered Annual Well-Child Visit
Jane takes her children, Joe and Jill, to their Primary Provider for an annual well-child visit including flu shots. These are 100% covered preventive services that cost $0 under both the PPO and the HMO. If there are no other non-preventive services, there is no copayment for the visit.

Office Visits - Primary Care
Joe is ill and Jane takes him to his Riverside Medical Group Primary Provider. She shows her Riverside identification badge and asks for the 25% employee discount.

  • Under the PPO, the cost is $11.25 ($15.00 copayment minus the 25% discount.)
  • Under the HMO, the cost would be $18.75 ($25.00 copayment minus the 25% discount.)

Jane injures her knee and goes to her Riverside Medical Group Primary Provider who performs an X-ray and reads it in-house.

  • Under the PPO, the cost is $11.25 (after 25% discount) for the office visit plus the cost of the X-ray. The X-ray allowable charge (the amount the health care providers in the network have agreed to accept for their services) is $40.00. Jane’s coinsurance is $8.00 (20% of $40.00) and she gets the employee discount. Her final cost for the X-ray is $6.00 ($8.00 minus the 25% discount). Her total under the PPO is $17.25 ($11.25 office visit plus $6.00 X-ray.)
  • Under the HMO, her office visit is $18.75 ($25.00 minus the 25% discount). The X-ray is included in the office visit under the HMO if performed by the same provider on the same day.

Office Visits - Specialist
Jane’s primary doctor decides that Jane should see an orthopedic specialist about her injured knee. Jane’s specialist is a Riverside Medical Group provider. The orthopedist performs two more X-rays in-house and reads them in-house.

  • Under the PPO, the office visit costs $37.50 ($50.00 minus the 25% discount) plus $12.00 (20% of $80.00 for 2 X-rays minus the 25% discount) for a total of $49.50.
  • Under the HMO, the cost would be $37.50 ($50.00 minus the 25% discount); X-rays are included in the cost of this office visit.

Advanced Imaging
Jane’s specialist sends her to a Riverside Imaging Center for an MRI of her knee. The allowable charge for this MRI is $2,000.

  • Under the PPO, it would cost Jane $300 (20% of the allowable charge minus the 25% employee discount). There is no deductible in the PPO.
  • Under the HMO, it would cost Jane $712.50 ($500 deductible + $450, the 30% coinsurance of remaining $1,500, minus the 25% employee discount.)

Please remember that this type of procedure may have multiple providers under both the PPO and HMO, and you may receive bills from each provider.

Outpatient Surgery
Jane’s knee injury requires outpatient surgery. She has the procedure at a Riverside facility and the total allowable charge is $5,000.

  • Under the PPO, she would owe $750, (20% of the allowable charge minus the 25% employee discount). There is no deductible in the PPO.
  • Under the HMO, since she has already met the $500 calendar year deductible for the previous MRI, she would owe $1,125 (30% coinsurance minus the 25% employee discount.)

This type of procedure may have multiple providers under both the PPO and HMO, and you may receive bills from each provider.

Out-of-Pocket Maximum
The maximum any individual (John, Jane, Joe, or Jill) will pay for out-of-pocket costs under the Riverside CareAdvantage PPO or Anthem HealthKeepers HMO per calendar year is $3,500. The most a family will pay in one calendar year is $7,000. (The family out-of-pocket maximum could be reached if John has $3,500 in costs, Jane has $3,000 in costs and Joe has $500 in costs or by any other combination.) All covered services are at $0 cost once you reach the out-of-pocket maximum. Discounts, coinsurance and copays count toward the out-of-pocket maximum.

Medical Flexible Spending Account
If you are enrolled in the Medical Flexible Spending Account in 2013, you may use the account’s debit card to pay for eligible out-of-pocket medical expenses at Riverside providers.

Please note that these are just examples of what costs may be. Your actual costs may be different based on the services performed. Please consider your personal health situation and that of your family when choosing your health insurance plan for 2013.


 

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