Common use of Cost Share for Covered Services Clause in Contracts

Cost Share for Covered Services. Allowed Charges and capitation Participating Providers agree to accept the Allowed Charges as payment in full for Covered Services provided or arranged by Blue Shield, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group are paid for by capitation payments. Every month, Blue Shield pays a set dollar amount to the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when you need them. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed Charges. You are only required to pay your Cost Share for those services. When you see a Participating Provider, you are responsible for your Cost Share. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an individual Member and an entire Family. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if:  You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract;  You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or  You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, and these amounts count toward your Out-of- Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will have a separate Out-of-Pocket Maximum for each individual Member and one for the entire Family. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum:  Charges for services that are not covered;  Charges over the Allowed Charges; and  Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum.

Cost Share for Covered Services. Allowed Charges and capitation Participating Providers agree to accept the Allowed Charges as payment in full for Covered Services provided or arranged by Blue Shield, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group are paid for by capitation payments. Every month, Blue Shield pays a set dollar amount to the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when you need them. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed Charges. You are only required to pay your Cost Share for those services. When you see a Participating Provider, you are responsible for your Cost Share. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an individual Member and an entire Family. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if:  You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract;  You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or  You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, and these amounts count toward your Out-of- Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer ServiceShield Concierge. If you have a Family plan, you will have a separate Out-of-Pocket Maximum for each individual Member and one for the entire Family. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum:  Charges for services that are not covered;  Charges over the Allowed Charges; and  Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum.

Cost Share for Covered Services. Allowed Charges and capitation Participating Providers agree to accept the Allowed Charges as payment in full for Covered Services provided or arranged by Blue Shield, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group are paid for by capitation payments. Every month, Blue Shield pays a set dollar amount to the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when you need them. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed Charges. You are only required to pay your Cost Share for those services. When you see a Participating Provider, you are responsible for your Cost Share. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an individual Member and an entire Family. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if:  • You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract;  • You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or  • You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, and these amounts count toward your Out-of- Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will have a separate Out-of-Pocket Maximum for each individual Member and one for the entire Family. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum:  • Charges for services that are not covered;  • Charges over the Allowed Charges; and  • Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum.

Cost Share for Covered Services. Allowed Charges and capitation Participating Providers agree to accept the Allowed Charges as payment in full for Covered Services provided or arranged by Blue Shield, except as stated in the Exception for other coverage and Reductions – third party liability sections. Covered Services provided or arranged by the Medical Group are paid for by capitation payments. Every month, Blue Shield pays a set dollar amount to the Medical Group for each enrolled Member. The capitation payments are available to cover the cost of services when you need them. If there is a payment dispute between Blue Shield and a Participating Provider over Covered Services you receive, the Participating Provider must resolve that dispute with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed Charges. You are only required to pay your Cost Share for those services. When you see a Participating Provider, you are responsible for your Cost Share. Calendar Year Deductible The Deductible is the amount you pay each Calendar Year for Covered Services before Blue Shield begins payment. Blue Shield will pay for some Covered Services before you meet your Deductible. Amounts you pay toward your Deductible count toward your Out-of-Pocket Maximum. Some plans do not have a Deductible. For plans that do, there may be separate Deductibles for an individual Member and an entire Family. If you have a Family plan, there is an individual Deductible within the Family Deductible. This means an individual family member can meet the individual Deductible before the entire Family meets the Family Deductible. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Deductible for your individual plan will be applied to both the individual Deductible and the Family Deductible for your new plan. See the Summary of Benefits section for details on which Covered Services are subject to the Deductible and how the Deductible works for your plan. Prior carrier Deductible credit If you pay all or part of a Deductible for another Employer-sponsored health plan in the same Calendar Year you enroll in this plan, that amount will be applied to this plan’s Deductible if:  • You were enrolled in an Employer-sponsored health plan with another carrier during the same Calendar Year this contract becomes effective and you enroll as of the original effective date of coverage under this contract;  • You were enrolled in another Blue Shield plan sponsored by the same Employer which this plan is replacing; or  • You were enrolled in another Blue Shield plan sponsored by the same Employer and you are transferring to this plan during open enrollment. Copayment and Coinsurance A Covered Service may have a Copayment or a Coinsurance. A Copayment is a specific dollar amount you pay for a Covered Service. A Coinsurance is a percentage of the Allowed Charges you pay for a Covered Service. Your provider will ask you to pay your Copayment or Coinsurance at the time of service. For Covered Services that are subject to your plan’s Deductible, you are also responsible for all costs up to the Allowed Charges until you reach your Deductible. You will continue to pay the Copayment or Coinsurance for each Covered Service you receive until you reach your Out-of-Pocket Maximum. Calendar Year Out-of-Pocket Maximum The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for Covered Services in a Calendar Year. Your Cost Share includes Deductible, Copayment, and Coinsurance, and these amounts count toward your Out-of- of-Pocket Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services for the rest of the Calendar Year. If you want information about your Out-of-Pocket Maximum, you can call Customer Service. If you have a Family plan, you will have a separate Out-of-Pocket Maximum for each individual Member and one for the entire Family. If you have a Family plan, there is an individual Out-of-Pocket Maximum within the Family Out-of-Pocket Maximum. This means an individual family member can meet the individual Out-of-Pocket Maximum before the entire Family meets the Family Out-of-Pocket Maximum. If you have an individual plan and you enroll a Dependent, your plan will become a Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your individual plan will be applied to both the individual Out-of-Pocket Maximum and the Family Out-of-Pocket Maximum for your new plan. The following do not count toward your Out-of-Pocket Maximum:  • Charges for services that are not covered;  • Charges over the Allowed Charges; and  • Charges for services over any Benefit maximum. You will continue to be responsible for these costs even after you reach your Out-of- Pocket Maximum. See the Summary of Benefits section for details on how the Out-of-Pocket Maximum works for your plan. Accrual balance Blue Shield provides a summary of your accrual balances toward your Calendar Year Deductible, if any, and Out-of-Pocket Maximum for every month in which your Benefits were used until the full amount has been met. This summary will be mailed to you unless you opt to receive it electronically or have already opted out of paper mailings. You can opt back in to receive paper mailings at any time or elect to receive your balance summary electronically by logging into your member portal online and updating your communication preferences, or by calling Customer Service at the number on the back of your ID card. You can also check your accrual balances at any time by logging into your member portal online, which is updated daily, or calling Customer Service. Your accrual balance information is updated once a claim is received and processed and may not reflect recent services. Cost Share concepts in action To recap, you are responsible for all costs for Covered Services until you reach your Deductible. Once you reach your Deductible, Blue Shield will pay the Allowed Charges for Covered Services, minus your Copayment or Coinsurance amounts, until you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services. Exceptions are described above.