Insurance Company 1: Plan Option 1 Coverage Period: 1/1/2011 – 12/31/2011 Coverage Examples Coverage for: Individual + Spouse | Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the What does a Coverage Example Can I use Coverage Examples assumptions behind the show? to compare plans? Coverage Examples? For each treatment situation, the Coverage Yes. When you look at the Summary of Costs don’t include premiums. Example helps you see how deductibles, Benefits and Coverage for other plans, Sample care costs are based on national copayments, and coinsurance can add up. It you’ll find the same Coverage Examples. also helps you see what expenses might be left When you compare plans, check the averages supplied by the U.S. up to you to pay because the service or “Patient Pays” box in each example. The Department of Health and Human treatment isn’t covered or payment is limited. smaller that number, the more coverage Services, and aren’t specific to a the plan provides. particular geographic area or health plan. Does the Coverage Example The patient’s condition was not an excluded or preexisting condition. predict my own care needs? Are there other costs I should All services and treatments started and  No. Treatments shown are just examples. consider when comparing ended in the same coverage period. The care you would receive for this plans? There are no other medical expenses for condition could be different based on your any member covered under this plan. doctor’s advice, your age, how serious your Yes. An important cost is the premium Out-of-pocket expenses are based only condition is, and many other factors. you pay. Generally, the lower your on treating the condition in the example. premium, the more you’ll pay in out-of- The patient received all care from in- Does the Coverage Example pocket costs, such as copayments, network providers. If the patient had deductibles, and coinsurance. You received care from out-of-network predict my future expenses? should also consider contributions to providers, costs would have been higher.  No. Coverage Examples are not cost accounts such as health savings accounts (HSAs), flexible spending arrangements estimators. You can’t use the examples to (FSAs) or health reimbursement accounts estimate costs for an actual condition. They (HRAs) that help you pay out-of-pocket are for comparative purposes only. Your expenses. own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Questions: Call 1-800-[insert] or visit us at www.[insert]. If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 8 at www.[insert] or call 1-800-[insert] to request a copy.