Close Up:
Bobby And Max - Low Option Plan

WE OPEN ON: Bobby, who enrolled in the Low Option Plan as an Extended Coverage Program participant, and Max, Bobby's same-sex domestic partner. Max has bunions and goes to a network doctor. He knows that for doctor visits, he has to pay the coinsurance. Let's assume that Max has met the individual calendar-year deductible of $750. Let's also assume that the Fund pays 70% for network services, and that Max pays 30%. If his doctor's negotiated fee is $90, Max's share of that cost is 30% of $90, or $27.

Meanwhile, back at the ranch . . .

Bobby wants to see a doctor about a knee problem. He doesn't look for a network provider. He goes to the doctor he saw advertised in the trades who is a non-network provider. The doctor's visit sets him back $300, which he pays at the time, even though he's met his calendar-year deductible. When he sends in the bill for reimbursement, the Fund pays a smaller percentage, 60%, of R&C charges for non-network services, or a total of $102.

* This is the contracted rate. Otherwise, the charge would have been $250.

So, Bobby's stuck with paying $198, and Max had to pay just $27. Bobby doesn't like the way those numbers add up.

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