4. Assume that you are an individual. You have one MRI (costing $3,000 from an in-network endorsed physician) and one doctors visit (costing $300). All are from providers that are considered out-of-network (i.e., youll have to use a different coinsurance provision). How much would you have to pay under each plan? Remember to include premiums.

HDHC DATA:

HSA DATA:

Premium DATA:

High Deductible Wellness PPO Plan Summary of Benefits and Coverage Effective 01/01/2020 Benefits Out-of-Network Anthem BlueCard PPO Network January 1 through December 31 Plan Year Deductible Individual or EE+CH*/Family $1,300 or $3,900 (3x the Individual) $2,600 or $7,800 (2x the INN* Deductibles) Only an individual portion of the family deductible ($1,300 or $2,600) can be met by any one family member, once an individual family member's deductible is met that family member's benefits are paid at the appropriate coinsurance amount 20% 50% Individual = $4,050 Individual = $12,150 (3X INN OOPM) EE+CH/Family = $9,750 EE+CH/Family = $29,250 (3X INN OOPM) Member Coinsurance Out-of-Pocket Maximum (OOPM*) *Amount Includes Deductible 50% after deductible 50% after deductible 20% after deductible 20% after deductible No Charge 20% after deductible 50% after deductible No Charge No Charge 50% after deductible 50% after deductible No Charge 50% after deductible Office Services Office Exam Physician - illness Injury Office Exam Nurse Practitioner-Illness Injury BSU Quick Care Clinic - Illness/Injury Chronic Disease illness Visits Preventive Services Routine exams, tests and immunizations Routine Mammograms, pap tests and colonoscopies Tobacco Cessation Lab Charges? LabCorp, Quest Diagnostic/LabCard and American Health Network Diagnostic Lab Charges - Physician/Facility Outpatient Services Surgical Expenses - Facility Surgical Expenses - Physician Diagnostic X-ray Expenses - Facility Diagnostic X-ray Expenses - Physician Manipulation Therapy No Charge 20% after deductible 50% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible; 24 Day Visit Limitation 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible; 24 Day Visit Limitation High Deductible Wellness PPO Plan Summary of Benefits and Coverage Effective 01/01/2020 20% after deductible; 60 Day Visit Limitation 20% after deductible; 36 Day Visit Limitation 20% after deductible; 20 Day Visit Limitation 50% after deductible; 60 Day Visit Limitation 50% after deductible; 36 Day Visit Limitation 50% after deductible; 20 Day Visit Limitation 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible Physical, Speech and Occupational Therapy Cardiac Rehabilitation Pulmonary Rehabilitation Inpatient Services Pre-Admission Testing - Facility Pre-Admission Testing - Physician Surgical Expenses - Facility Surgical Expenses - Physician Inpatient Care - Facility Inpatient Care - Physician Skilled Nursing Facility Additional Services Emergency Room Illness and Accident Benefit Ambulance Benefit Substance Abuse Benefit Mental Health Benefit; Includes Residential Care Durable Medical Equipment Prosthetics/Orthotics Home Health Care Hospice Care Bariatric Services for Morbid Obesity ConditionCare Disease Management Solution Program Anthem Engage Cost & Quality Tool Advanced Imaging Management (AIM) 20% after $200 copay after deductible (copay is waived if admitted)-must satisfy emergency criteria 20% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible; additional criteria required 50% after deductible; additional criteria required N/A N/A N/A N/A N/A N/A *Abbreviations: EE+CH = Employee Plus Children INN = In-Network OOPM = Out-of-Pocket-Maximum Preventive care is provided when there are no current symptoms or history of medical conditions associated with a particular screening; all preventive services are limited to one of each service per year per covered member HSA Qualified Health Plan Summary of Benefits and Coverage Effective 01/01/2020 Benefits Out-of-Network Anthem BlueCard PPO Network January 1 through December 31 Plan Year Deductible Individual or EE+CH*/Family Member Coinsurance Out-of-Pocket Maximum (OOPM*) *Amount Includes Deductible $2,500 or $5,000 $2,500 or $5,000 EE+CH/Family coverage requires that the full EE+CH/Family deductible to be met before coinsurance applies; the individual deductible does not apply to EE+CH/Family coverage. Non-Preventive Prescription expenses are included in the medical deductible. 20% 50% Individual Plan (Employee Only) = $4,750 Individual = $6,450 EE+CH/Family = $8,250 (Individual Max OOP of EE+CH/Family = $12,900 $7,150) 50% after deductible 50% after deductible 20% after deductible 20% after deductible No Charge after deductible 20% after deductible 50% after deductible No Charge No Charge 50% after deductible 50% after deductible No Charge 50% after deductible Office Services Office Exam Physician - illness Injury Office Exam Nurse Practitioner - illness Injury BSU Quick Care Clinic - illness/Injury Chronic Disease illness Visits Preventive Services Routine exams, tests and immunizations Routine Mammograms, pap tests and colonoscopies Tobacco Cessation Lab Charges? LabCorp, Quest Diagnostic/LabCard and American Health Network Diagnostic Lab Charges - Physician/Facility Outpatient Services Surgical Expenses - Facility Surgical Expenses - Physician Diagnostic X-ray Expenses - Facility Diagnostic X-ray Expenses - Physician Manipulation Therapy Physical, Speech and Occupational Therapy No Charge after deductible 20% after deductible 50% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible; 24 Day Visit Limitation 20% after deductible; 60 Day Visit Limitation 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible; 24 Day Visit Limitation 50% after deductible; 60 Day Visit Limitation HSA Qualified Health Plan Summary of Benefits and Coverage Effective 01/01/2020 20% after deductible; 36 Day Visit Limitation 20% after deductible; 20 Day Visit Limitation 50% after deductible; 36 Day Visit Limitation 50% after deductible; 20 Day Visit Limitation 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible Cardiac Rehabilitation Pulmonary Rehabilitation Inpatient Services Pre-Admission Testing Facility Pre-Admission Testing - Physician Surgical Expenses - Facility Surgical Expenses - Physician Inpatient Care - Facility Inpatient Care - Physician Skilled Nursing Facility Additional Services Emergency Room Illness and Accident Benefit Ambulance Benefit Substance Abuse Benefit Mental Health Benefit Durable Medical Equipment Prosthetics/Orthotics Home Health Care Hospice Care Bariatric Services for Morbid Obesity ConditionCare Disease Management Solution Program Anthem Engage Cost & Quality Tool Advanced Imaging Management (AIM) 20% after $200 copay after deductible (copay is waived if admitted)-must satisfy emergency criteria 20% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible; additional criteria required 50% after deductible; additional criteria required N/A N/A N/A N/A N/A N/A **Abbreviations: EE+CH = Employee Plus Children INN = In-Network OOPM = Out-of-Pocket-Maximum Preventive care provided when there are no current symptoms or history of medical conditions associated with a particular screening, all preventive services are limited to one of each service per year per covered member. 2 This benefit is for blood work lab charges only. HEALTH PLAN PREMIUMS (Medical + Prescription) HSA Qualified High Deductible Health Plan Wellness Biweekly 10 12 10 12 month month month month (18 pays) (26 pays) (18 pays) (26 pays) $44.07 $30.51 $75.67 $52.39 TF = Tobacco Free Single TF Discount Single Full Rate $94.07 $65.12 $125.67 $87.01 EE+CH TF Discount $83.73 $57.97 $143.79 $99.55 EE+CH Full Rate $133.73 $92.59 $193.79 | $134.17 Family TF Discount $114.41 $79.21 $196.46 $136.01 Family Full Rate $164.41 $113.83 $246.46 $170.62 Biweekly DENTAL PLAN PREMIUMS 10 month (18 pays) 12 month (26 pays) Single $8.05 $5.57 EE+CH $15.25 $10.56 Family $20.81 $14.41 EE+CH = Employee Plus Child(ren) High Deductible Wellness PPO Plan Summary of Benefits and Coverage Effective 01/01/2020 Benefits Out-of-Network Anthem BlueCard PPO Network January 1 through December 31 Plan Year Deductible Individual or EE+CH*/Family $1,300 or $3,900 (3x the Individual) $2,600 or $7,800 (2x the INN* Deductibles) Only an individual portion of the family deductible ($1,300 or $2,600) can be met by any one family member, once an individual family member's deductible is met that family member's benefits are paid at the appropriate coinsurance amount 20% 50% Individual = $4,050 Individual = $12,150 (3X INN OOPM) EE+CH/Family = $9,750 EE+CH/Family = $29,250 (3X INN OOPM) Member Coinsurance Out-of-Pocket Maximum (OOPM*) *Amount Includes Deductible 50% after deductible 50% after deductible 20% after deductible 20% after deductible No Charge 20% after deductible 50% after deductible No Charge No Charge 50% after deductible 50% after deductible No Charge 50% after deductible Office Services Office Exam Physician - illness Injury Office Exam Nurse Practitioner-Illness Injury BSU Quick Care Clinic - Illness/Injury Chronic Disease illness Visits Preventive Services Routine exams, tests and immunizations Routine Mammograms, pap tests and colonoscopies Tobacco Cessation Lab Charges? LabCorp, Quest Diagnostic/LabCard and American Health Network Diagnostic Lab Charges - Physician/Facility Outpatient Services Surgical Expenses - Facility Surgical Expenses - Physician Diagnostic X-ray Expenses - Facility Diagnostic X-ray Expenses - Physician Manipulation Therapy No Charge 20% after deductible 50% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible; 24 Day Visit Limitation 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible; 24 Day Visit Limitation High Deductible Wellness PPO Plan Summary of Benefits and Coverage Effective 01/01/2020 20% after deductible; 60 Day Visit Limitation 20% after deductible; 36 Day Visit Limitation 20% after deductible; 20 Day Visit Limitation 50% after deductible; 60 Day Visit Limitation 50% after deductible; 36 Day Visit Limitation 50% after deductible; 20 Day Visit Limitation 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible Physical, Speech and Occupational Therapy Cardiac Rehabilitation Pulmonary Rehabilitation Inpatient Services Pre-Admission Testing - Facility Pre-Admission Testing - Physician Surgical Expenses - Facility Surgical Expenses - Physician Inpatient Care - Facility Inpatient Care - Physician Skilled Nursing Facility Additional Services Emergency Room Illness and Accident Benefit Ambulance Benefit Substance Abuse Benefit Mental Health Benefit; Includes Residential Care Durable Medical Equipment Prosthetics/Orthotics Home Health Care Hospice Care Bariatric Services for Morbid Obesity ConditionCare Disease Management Solution Program Anthem Engage Cost & Quality Tool Advanced Imaging Management (AIM) 20% after $200 copay after deductible (copay is waived if admitted)-must satisfy emergency criteria 20% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible; additional criteria required 50% after deductible; additional criteria required N/A N/A N/A N/A N/A N/A *Abbreviations: EE+CH = Employee Plus Children INN = In-Network OOPM = Out-of-Pocket-Maximum Preventive care is provided when there are no current symptoms or history of medical conditions associated with a particular screening; all preventive services are limited to one of each service per year per covered member HSA Qualified Health Plan Summary of Benefits and Coverage Effective 01/01/2020 Benefits Out-of-Network Anthem BlueCard PPO Network January 1 through December 31 Plan Year Deductible Individual or EE+CH*/Family Member Coinsurance Out-of-Pocket Maximum (OOPM*) *Amount Includes Deductible $2,500 or $5,000 $2,500 or $5,000 EE+CH/Family coverage requires that the full EE+CH/Family deductible to be met before coinsurance applies; the individual deductible does not apply to EE+CH/Family coverage. Non-Preventive Prescription expenses are included in the medical deductible. 20% 50% Individual Plan (Employee Only) = $4,750 Individual = $6,450 EE+CH/Family = $8,250 (Individual Max OOP of EE+CH/Family = $12,900 $7,150) 50% after deductible 50% after deductible 20% after deductible 20% after deductible No Charge after deductible 20% after deductible 50% after deductible No Charge No Charge 50% after deductible 50% after deductible No Charge 50% after deductible Office Services Office Exam Physician - illness Injury Office Exam Nurse Practitioner - illness Injury BSU Quick Care Clinic - illness/Injury Chronic Disease illness Visits Preventive Services Routine exams, tests and immunizations Routine Mammograms, pap tests and colonoscopies Tobacco Cessation Lab Charges? LabCorp, Quest Diagnostic/LabCard and American Health Network Diagnostic Lab Charges - Physician/Facility Outpatient Services Surgical Expenses - Facility Surgical Expenses - Physician Diagnostic X-ray Expenses - Facility Diagnostic X-ray Expenses - Physician Manipulation Therapy Physical, Speech and Occupational Therapy No Charge after deductible 20% after deductible 50% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible; 24 Day Visit Limitation 20% after deductible; 60 Day Visit Limitation 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible; 24 Day Visit Limitation 50% after deductible; 60 Day Visit Limitation HSA Qualified Health Plan Summary of Benefits and Coverage Effective 01/01/2020 20% after deductible; 36 Day Visit Limitation 20% after deductible; 20 Day Visit Limitation 50% after deductible; 36 Day Visit Limitation 50% after deductible; 20 Day Visit Limitation 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible 50% after deductible Cardiac Rehabilitation Pulmonary Rehabilitation Inpatient Services Pre-Admission Testing Facility Pre-Admission Testing - Physician Surgical Expenses - Facility Surgical Expenses - Physician Inpatient Care - Facility Inpatient Care - Physician Skilled Nursing Facility Additional Services Emergency Room Illness and Accident Benefit Ambulance Benefit Substance Abuse Benefit Mental Health Benefit Durable Medical Equipment Prosthetics/Orthotics Home Health Care Hospice Care Bariatric Services for Morbid Obesity ConditionCare Disease Management Solution Program Anthem Engage Cost & Quality Tool Advanced Imaging Management (AIM) 20% after $200 copay after deductible (copay is waived if admitted)-must satisfy emergency criteria 20% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible 50% after deductible 20% after deductible; additional criteria required 50% after deductible; additional criteria required N/A N/A N/A N/A N/A N/A **Abbreviations: EE+CH = Employee Plus Children INN = In-Network OOPM = Out-of-Pocket-Maximum Preventive care provided when there are no current symptoms or history of medical conditions associated with a particular screening, all preventive services are limited to one of each service per year per covered member. 2 This benefit is for blood work lab charges only. HEALTH PLAN PREMIUMS (Medical + Prescription) HSA Qualified High Deductible Health Plan Wellness Biweekly 10 12 10 12 month month month month (18 pays) (26 pays) (18 pays) (26 pays) $44.07 $30.51 $75.67 $52.39 TF = Tobacco Free Single TF Discount Single Full Rate $94.07 $65.12 $125.67 $87.01 EE+CH TF Discount $83.73 $57.97 $143.79 $99.55 EE+CH Full Rate $133.73 $92.59 $193.79 | $134.17 Family TF Discount $114.41 $79.21 $196.46 $136.01 Family Full Rate $164.41 $113.83 $246.46 $170.62 Biweekly DENTAL PLAN PREMIUMS 10 month (18 pays) 12 month (26 pays) Single $8.05 $5.57 EE+CH $15.25 $10.56 Family $20.81 $14.41 EE+CH = Employee Plus Child(ren)