PRATT REGIONAL MEDICAL CENTER: PREMIUM PLAN Coverage Period: 01/01/2017 – 12/31/2017
Coverage Examples Coverage for: Family | Plan Type: PPO
Questions: Call 1-800-290-1368 or visit us at www.bmikansas.com.
If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-290-1368 to request a copy.
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
• Costs don’t include premiums.
• Sample care costs are based on national
averages supplied by the U.S.
Department of Health and Human
Services, and aren’t specific to a
particular geographic area or health plan.
• The patient’s condition was not an
excluded or preexisting condition.
• All services and treatments started and
ended in the same coverage period.
• There are no other medical expenses for
any member covered under this plan.
• Out-of-pocket expenses are based only
on treating the condition in the example.
• The patient received all care from in-
network providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
What does a Coverage Example
For each treatment situation, the Coverage
Example helps you see how deductibles, co-
payments, and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on
the care you receive, the prices your
providers charge, and the reimbursement
your health plan allows.
Can I use Coverage Examples
to compare plans?
Yes. When you look at the Summary of
Benefits and Coverage for other plans,
you’ll find the same Coverage Examples.
When you compare plans, check the
“Patient Pays” box in each example. The
smaller that number, the more coverage
the plan provides.
Are there other costs I should
consider when comparing
Yes. An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in out-of-
pocket costs, such as co-payments,
deductibles, and co-insurance. You
should also consider contributions to
accounts such as health savings accounts
(HSAs), flexible spending arrangements
(FSAs) or health reimbursement accounts
(HRAs) that help you pay out-of-pocket