Page 62 - Tampa Bay Rays 2022 Flipbook

How your Gap plan works

Sample In-Hospital Claim: Heart Condition
Health Plan Your 80% Health Plan
Charges per Explanation of Benefit (EOB) $52,034 Charges per Explanation of Benefit (EOB) $52,034

Major Medical Plan Deductible -$0 Major Medical Plan Deductible -$300
Major Medical Plan Coinsurance (0%) $0 Major Medical Plan Coinsurance $1,500
(Maximum Out-of-Pocket ($0)) (Maximum Out-of-Pocket ($1,500))
Employee Out-of-Pocket responsibility $0 Employee Out-of-Pocket responsibility $1,800

Your Kemper Health Gap In-Patient Benefit Paid $1,800
Employee Net Out-of-Pocket Expense $0 Employee Net Out-of-Pocket Expense $0

Sample Out-of-Hospital Claim: Emergency Room Accident - Broken Wrist
Health Plan Your 80% Health Plan
Charges per Explanation of Benefit (EOB) $4,660 Charges per Explanation of Benefit (EOB) $4,660
Major Medical Plan Deductible -$100 Major Medical Plan Deductible -$100

Major Medical Plan Coinsurance (0%) $0 Major Medical Plan Coinsurance (20%) $912
(Maximum Out-of-Pocket ($0)) (Maximum Out-of-Pocket ($1,500))
Employee Out-of-Pocket responsibility $100 Employee Out-of-Pocket responsibility $1,012
Your Kemper Health Gap In-Patient Benefit Paid $1,000

Employee Net Out-of-Pocket Expense $100 Employee Net Out-of-Pocket Expense $12

This is a sample Doctor’s Office Claim: X-Ray of Ankle in Doctor’s Office
Health Plan Your 80% Health Plan
Charges per Explanation of Benefit (EOB) $342 Charges per Explanation of Benefit (EOB) $342

Major Medical Plan Deductible -$0 Major Medical Plan Deductible -$300
Physician’s Office Visit Copay $15 Physician’s Office Visit Copay $15

Employee Out-of-Pocket responsibility $15 Employee Out-of-Pocket responsibility $315

Your Kemper Health Gap In-Patient Benefit Paid N/A
Employee Net Out-of-Pocket Expense $15 Employee Net Out-of-Pocket Expense $315

Sample Out-of-Hospital Claim: X-Ray of Ankle in a Freestanding Surgical Center
Health Plan Your 80% Health Plan
Charges per Explanation of Benefit (EOB) $509 Charges per Explanation of Benefit (EOB) $509

Major Medical Plan Deductible -$0 Major Medical Plan Deductible -$300
Major Medical Plan Coinsurance (0%) $0 Major Medical Plan Coinsurance (20%) $42
(Maximum Out-of-Pocket ($0)) (Maximum Out-of-Pocket ($1,500))
Employee Out-of-Pocket responsibility $0 Employee Out-of-Pocket responsibility $342
Your Kemper Health Gap In-Patient Benefit Paid $342

Employee Net Out-of-Pocket Expense $0 Employee Net Out-of-Pocket Expense $0

The above examples are for illustrative purposes only, and may not reflect the results of an insured’s actual claim. Major medical is not a Kemper
Health product, and each insured should determine the benefits, deductibles, copays, exclusions, terms and conditions of his/her major medical
based on hospital, length of hospital stay, physician, network participation, geographic area, patient’s diagnosis, treatment and/or other factors.