These examples show how HMSA calculates your coinsurance for covered services if your HMSA plan pays 90% of the eligible charge when you see a participating provider and 70% when you see a nonparticipating provider. Coinsurance may differ. Refer to your Guide to Benefits for your specific coinsurance.

Physician visit

When your coinsurance is 10% of the eligible charge for services from a participating physician and 30% for services from a nonparticipating physician:

You have a cold and go to a participating physician to have it checked out.

• The physician’s bill or actual charge is $100.
• HMSA’s eligible charge is $80.
• Your coinsurance is $8 (10% of $80).

If you went to a nonparticipating physician, you’d owe a coinsurance of 30% of the eligible charge plus the difference between the eligible charge and the physician’s actual charge. The nonparticipating physician may require payment of the actual charge at the time of service.

• The physician’s bill or actual charge is $100.
• HMSA’s eligible charge is $80.
• HMSA will reimburse you $56 (70% of $80).
• Your total out-of-pocket cost is $44.

*Note: Because services were provided by a nonparticipating physician, your physician may require payment of the actual charge of $100 and you may need to file your own claim.

Surgical procedure — physician charge

When your coinsurance is 10% of the eligible charge for services from a participating physician and 30% for services from a nonparticipating physician:

You have a major surgical procedure done by a participating physician.

• The physician’s bill or actual charge is $100,000.
• HMSA’s eligible charge is $40,000.
• Your coinsurance is $4,000 (10% of $40,000).

If you went to a nonparticipating provider, you’d owe a coinsurance of 30% of the eligible charge plus the difference between the eligible charge and the physician’s actual charge. The nonparticipating physician may require payment of the actual charge at the time of service.

• The physician’s bill or actual charge is $100,000.
• HMSA’s eligible charge is $40,000.
• HMSA will reimburse you $28,000 (70% of $40,000).
• Your total out-of-pocket cost is $72,000.

*Note: Because services were provided by a nonparticipating physician, your physician may require payment of the actual charge of $100,000 and you may need to file your own claim.