Plan | Basic | Enhanced | Premier | Exclusive |
Annual Limit for Hospital & Surgical | $60,000 | $60,000 | $80,000 | $80,000 |
Waiver of Co-payment (25%) | No | Yes | Yes | Yes |
Scenario 1:
Helper incurs a $15,000 hospital bill for a necessary procedure | We will cover the total bill of $15,000 |
Scenario 2:
Helper incurs a $30,000 hospital bill for a necessary procedure | We will cover the first $15,000
Next $15,000
Co-payment applies
Employer: 25% x $15,000 = $3,750
Remaining
$15,000-$3,750
=$11,250
Out of the total $30,000 bill
Insurer will pay
$15,000 + $11,250 = $26,250
Employer will have to pay
$3,750 | We will cover the first $15,000
Next $15,000
Co-payment will be waived
Employer = $0
Insurer = Settle the total $30,000
| We will cover the first $15,000
Next $15,000
Co-payment will be waived
Employer = $0
Insurer = Settle the total $30,000
|
Balance claimable limit for the year | $60,000 – $26,250 = $33,750 | $60,000 – $30,000 = $30,000 | $80,000 – $30,000 = $50,000 |
Scenario 3:
Helper incurs a $75,000 hospital bill for a necessary procedure | We will cover the first $15,000 (a)
Next $60,000
Co-payment 25% applies
$60,000 x 25% = $15,000 (b)
Remaining 75%
$60,000 - $15,000
=$45,000 (c)
Out of the total $75,000 bill
Insurer will pay
(a) $15,000
(c) $45,000 (Benefit limit reached)
We will pay up to annual limit $60,000
Employer will have to pay
(b) $15,000
| We will cover the first $15,000 (a)
Next $60,000
Co-payment 25% will be waived
$60,000 x 25% = $15,000 (b)
Remaining 75%
$60,000 - $15,000
=$45,000 (c)
Out of the total $75,000 bill
Insurer will pay
(a) $15,000
(b) $15,000
(c) $30,000 (Benefit limit reached)
We will pay up to annual limit $60,000
Employer will have to pay
(c) $15,000
| We will cover the first $15,000 (a)
Next $60,000
Co-payment 25% will be waived
$60,000 x 25% = $15,000 (b)
Remaining 75%
$60,000 - $15,000
=$45,000 (c)
Out of the total $75,000 bill
Insurer will pay
(a) $15,000
(b) $15,000
(c) $45,000
We will pay the total bill $75,000
Employer will have to pay
(c) $0
|
Balance claimable limit for the year | $60,000 – $60,000 = $0 | $60,000 – $60,000 = $0 | $80,000 – $75,000 = $5,000 |