Overview
The purpose of this page is to show how the UNI PPO (Alliance Select) Plan works, who pays, and when. The below is an example of how the family plan works.
Self-insured Health Plans: 101
| Term | Definition | Amount |
|---|---|---|
| Copayment | A fixed amount you pay for a covered health care service, usually when you receive the service. | $15 for each in-network office, urgent care, & specialist visit |
| Deductible | The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. | $300 per person, with a maximum of $600 per family |
| Coinsurance | Your share of the costs of a covered health care service after the deductible is met. This is calculated as a percent of the allowed amount for the service and will be owed until the max out-of-pocket is met. | 10% in-network coinsurance |
| Max out-of-pocket (MOP) | This is the most you could pay during a coverage period (one calendar year, January - December) for your share of the cost of covered services. This limit helps you plan for health care expenses. Copyaments, deductibles, and coinsurance all contribute towards your max out-of-pocket total. Premiums, pre-service review penalties, and balance-billed charges do not go towards your max out-of-pocket. | $1,500 per person, with a maximum of $3,000 per family
The Prescription MOP is $1,600 per person, with a maximum of $3,200 per family |
| In-Network | Providers who contract with your health plan. Your payments may be less when seeking treatment from an in-network facility or physician. |
Service 1
After your nightly jog, you notice that your left knee is very sore and remains sore overnight. You decide to go to the doctor to make sure it is not anything more serious.
You elect to visit a specialist who is in-network, saving both you and the plan money, as Wellmark has negotiated maximum allowable prices for services with in-network providers.
The total cost of the specialist is $220.
With the UNI PPO (Alliance Select) Family Plan, there is a copay for specialist visits which is $15 (your responsibility to pay) and the plan reserve pays the remaining $205 (plan's responsibility to pay).
| Medical Max out-of-pocket
(MOP) |
Per
Person |
(Maximum)
Per Family |
|---|---|---|
| Beginning Balance | $1,500 | $3,000 |
| Specialist Copay | ($15) | ($15) |
| Remaining MOP | $1,485 | $2,985 |
Service 2
The specialists recommends X-rays on the knee to aid in diagnosing the origin of the pain.
The in-network specialist saves both you and the plan money, as Wellmark has negotiated maximum allowable prices for services with in-network providers.
The total cost of the X-rays are $600.
With the UNI PPO Plan, there is an out-of-pocket deductible of $300 for each individual on the plan, once a combined total of $600 is met for the family, the family deductible is satisfied. You are responsible for the full $300 amount as an individual on the plan. With the UNI PPO Plan you have satisified the individual deductible and are now in the coinsurance phase, and you share costs with the plan for the covered services. You owe 10% coinsurance on the remaining $300 ($600 - $300 deductible). The coinsurance for this service would be $30.
| Medical Max out-of-pocket
(MOP) |
Per
Person |
(Maximum)
Per Family |
|---|---|---|
| Beginning Balance | $1,485 | $2,985 |
| Deductible | ($300) | ($300) |
| Coinsurance | ($30) | ($30) |
| Remaining MOP | $1,155 | $2,655 |
Service 3
Based on the results of the X-rays, it is determined that best treatment for the pain is arthroscopic meniscus repair surgery, a minimally invasive method to repair torn knee cartilage.
The surgery and recovery will take place at an in-network facility and Wellmark has negotiated maximum allowable prices for services with in-network facilities and providers.
The total cost facility and surgeon fees are $13,500.
You are now in the coinsurance phase, and you share costs with the plan for the covered services. You owe 10% coinsurance of the facility and surgeon fees of $1,350 (10% of $13,500), up to the point you reach your per person medical MOP, and the plan reserve pays the remainder. However, because your MOP is $1,500 per person and you have already paid a $15 copay, the $300 deductible, and $30 coinsurance, you only owe the difference of $1,155. The plan will then pay $12,345.
| Medical Max out-of-pocket
(MOP) |
Per
Person |
(Maximum)
Per Family |
|---|---|---|
| Beginning Balance | $1,155 | $2,655 |
| Coinsurance | ($1,155) | ($1,155) |
| Remaining MOP | $0 | $1,500 |
Summary
These scenarios are designed to help you understand the phases of healthcare of the UNI PPO Plan and payment at the different levels.
In these scenarios for the UNI PPO Plan the copayment, deductible, and coinsurance all count towards meeting the annual max out-of-pocket. Adding these scenarios up, your out-of-pocket expenses would be $1,500, plus the annual premium, and the plan
reserve paid $12,820.
If you have additional questions on how the plans work, please contact the HRS Benefits team at
hrs-benefits@uni.edu.
The information displayed on this page is designed to help you make informed choices about your healthcare benefits. This information is not intended to be a guarantee of your costs or benefits. Your actual costs and/or benefits may vary. Refer to your health plan materials for information regarding your specific benefits and to determine covered medical and prescription expenses.