| Example: Out-Of-Network Provider |
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| Example of how we pay benefits when you use an out-of-network provider |
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Example:
Out-of-network provider’s charge for a service
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$50.00 |
Amount allowed to an in-network provider for the same service
(the contracted amount)
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$45.00 |
How that covered expense would be paid
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Contract coinsurance (supposing deductible has been satisfied)
(OMIP benefit is 60%, your responsibility is 40%)
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40% |
Amount OMIP would pay to the out-of-network provider
(60% of $45.00)
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$27.00 |
Amount you would pay to the out-of-network provider
(40% of $45.00 + the $5.00 difference between the amount
billed and the amount allowed)
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$23.00 |
Total the out-of-network provider receives
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$50.00 |
This is only an example. They assume that you have met any applicable deductible, but have not met the maximum out-of-pocket limit. The actual benefits of the Contract you choose will vary. You will need to read your actual Contract to determine how your benefits under the Contract will be paid.
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