Close Up:
Jimmy And Lynn - Regular Plan

WE OPEN ON: Jimmy's wife, Lynn, who has bronchitis and goes to a network doctor. She knows that for doctor's visits, she doesn't have to pay a copay, but she does have to pay the coinsurance. Let's assume that Lynn has already met her individual calendar-year deductible of $300. Let's also assume that the Fund pays 85% of the contracted rate for network services, which makes Lynn's coinsurance 15%. Lynn's doctor sends a bill for $120, but because his contracted rate is $90 for that service, Lynn's share of that cost is 15% of $90, or $13.50.

Meanwhile, back at the ranch . . .

Jimmy needs to go to the doctor (but he won't say why because that's private information). Let's assume that Jimmy has already met his individual calendar-year deductible. He always lets his business manager worry about bills, so he doesn't try to find a network provider. Instead, he goes to a hot new doctor in Beverly Hills. The doctor charges $300 for the visit and Jimmy has to pay it up-front. The Fund will pay a percentage of R&C charges for non-network services, and Jimmy is responsible for paying the balance.

Jimmy is responsible for $181 - or he would have been if he had remembered to send the invoice into the Administrative Office for reimbursement, or even given it to his business manager to handle.

Note: Costs cited in this example are for illustrative purposes only. Your own costs may be different.