•
Copayments
are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
•
Coinsurance
is
your
share of the costs of a covered service, calculated as a percent of the
allowed amount
for the service. For example, if the plan’s
allowed
amount
for an overnight hospital stay is $1,000, your
coinsurance
payment of 20% would be $200. This may change if you haven’t met your
deductible
.
• The amount the plan pays for covered services is based on the
allowed amount
. If an out-of-network
provider
charges more than the
allowed amount
, you may have
to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the
allowed amount
is $1,000, you may have to pay the $500
difference. (This is called
balance billing
.)
• This plan encourages you to use Banner Health Network
providers
by charging you lower
deductibles
,
copayments
and
coinsurance
amounts when you use a
participating physician or hospital in the Banner Health Network. When you use a physician or hospital that is not part of the Banner Health Network but in Aetna's
general network (an "In-Network Provider" in the chart below), you will pay higher out-of-pocket costs. There is no coverage when you receive care from out-of-network
providers, except for emergency care.
Common Medical Event
Services You May
Need
Your cost if you use
a Banner Health
Network Provider
Your cost if you use an
In-Network Provider
Your cost if
you use an
Out-of-
Network
Provider
Limitations & Exceptions
If you visit a health care
provider’s office or clinic
Primary care visit to
treat an injury or illness
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
Specialist visit
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
Other practitioner
office visit
20%
coinsurance
40%
coinsurance
Not covered
Chiropractic care (limited to 26 visits per
calendar year). Acupuncture only covered
in lieu of anesthesia.
No out-of-network coverage.
Preventive care/
screening/
immunization
No charge
No charge
Not covered
Age and frequency schedules may apply.
No out-of-network coverage.
If you have a test
Diagnostic test (x-ray,
blood work)
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
Imaging
(CT/PET scans, MRIs)
20%
coinsurance
40%
coinsurance
Not covered No out-of-network coverage.
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