| Member Payment Examples in PEBB's Statewide Plan 2010 |
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These examples illustrate PEBB-member coinsurance payments for costs of covered medical services in the Statewide Plan beginning 2010. The examples address services from in-network and out-of-network medical providers, and in both urban areas and designated rural counties.
The plan administrator determines the plan’s payment for covered services. In-network providers accept contracted payments for covered services. Out-of-network providers do not share this agreement.
Members who live in rural areas may not have ready access to in-network providers. PEBB applies an implicit subsidy to claims from providers in rural counties. The designated rural counties are: Baker, Crook, Curry, Deschutes, Gilliam, Grant, Harney, Jackson, Jefferson, Josephine, Klamath, Lake, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, and Wheeler (and out-of-state areas immediately adjacent to these counties).
Here’s how payments work.
Urban Areas
You see an In-network Provider who charges a $100 fee.
- The plan covers a $90 fee. The plan pays 85% of $90 (0.85 X $90): $76.50.
- You pay 15% of $90 (0.15 X $90): $13.50.
- The in-network provider accepts $90 payment.
You see an Out-of-network Provider who charges a $100 fee
- The plan covers a $90 fee. The plan pays 70% of $90 (0.70 X $90): $66.50
- You pay 30% of $90 (0.30 X $90): $33.50
- The out-of-network provider may accept the $90 you and the plan have paid as payment in full or may bill you for the fee-balance of $10.
Designated Rural Counties
You see an Out-of-network Provider who charges a $100 fee.
- The plan covers a $90 fee. The plan pays 85% of $90 (0.85 X $90): $76.50.
- You pay 15% of $90 (0.15 X $90): $13.50.
- The out-of-network provider may accept the $90 you and the plan have paid as payment in full or may bill your for the fee-balance of $10.
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