PPO II - EmblemHealth

2013 Evidence of Coverage for PPO II) II
Chapter 3. 4: Using Medical the Benefi plan’s ts coverage Chart (what for your is covered medical and services what you pay)
SECTION 1 UNDERSTANDING YOUR OUT-OF-POCKET
COSTS FOR COVERED SERVICES
Th is chapter focuses on your covered services and what you pay for your medical benefi ts. It includes
a Medical Benefi ts Chart that lists your covered services and shows how much you will pay for each
covered service as a member of our plan. Later in this chapter, you can fi nd information about medical
services that are not covered. It also explains limits on certain services.
Section 1.1 Types of out-of-pocket costs you may pay
for your covered services
To understand the payment information we give you in this chapter, you need to know about the types
of out-of-pocket costs you may pay for your covered services.
• A “copayment” is the fi xed amount you pay each time you receive certain medical services. You
pay a copayment at the time you get the medical service. (Th e Medical Benefi ts Chart in Section
2 tells you more about your copayments.)
• “Coinsurance” is the percentage you pay of the total cost of certain medical services. You pay
a coinsurance at the time you get the medical service. (Th e Medical Benefi ts Chart in Section 2
tells you more about your coinsurance.)
Some people qualify for State Medicaid programs to help them pay their out-of-pocket costs for
Medicare. (Th ese “Medicare Savings Programs” include the Qualifi ed Medicare Benefi ciary (QMB),
Specifi ed Low-Income Medicare Benefi ciary (SLMB), Qualifying Individual (QI), and Qualifi ed
Disabled & Working Individuals (QDWI) programs.) If you are enrolled in one of these programs, you
may still have to pay a copayment for the service, depending on the rules in your state.
Section 1.2 What is the most you will pay for Medicare Part A and
Part B covered medical services?
Under our plan, there are two diff erent limits on what you have to pay out-of-pocket for covered
medical services:
• Your in-network maximum out-of-pocket amount is $3,400. Th is is the most you pay during
the calendar year for covered Medicare Part A and Part B services received from in-network
providers. Th e amounts you pay for copayments and coinsurance for covered services from
in-network providers count toward this in-network maximum out-of-pocket amount. (Th e
amounts you pay for plan premiums, Part D prescription drugs, and services from out-ofnetwork
providers do not count toward your in-network maximum out-of-pocket amount. In
addition, amounts you pay for some services do not count toward your in-network maximum
out-of-pocket amount. Th ese services are marked as supplemental benefi ts in the Medical
Benefi ts Chart.) If you have paid $3,400 for covered Part A and Part B services from in-network
providers, you will not have any out-of-pocket costs for the rest of the year when you see our
network providers. However, you must continue to pay your plan premium and the Medicare
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