Peace of Mind

Insurance can give you financial security and peace of mind, especially in case of unexpected expenses.

When do people use insurance?

Lesson Objective

Calculate the amount the patient pays for health care.

Content Vocabulary

deductibledeductible

The amount of money you must pay each year before your insurance company starts paying.

deductible

The amount of money you must pay each year before your insurance company starts paying.

co-insurance

co-payment

co-insurance

Requires you to pay either a set amount or a certain percent of medical expenses.

co-insurance

Requires you to pay either a set amount or a certain percent of medical expenses.

co-payment

A predetermined flat fee you pay for health care services.

co-payment

A predetermined flat fee you pay for health care services.

Brooke Kolodie is single and has a health insurance plan with the benefits shown in Figure 11.1 on page 421 or your textbook.

Her recent network health costs include co-payments for 8 physician visits and 9 specialist visits.

Example 1Example 1

Following hospital surgery, she made co-payments for 12 physical therapy visits at $85 each and she had co-payments at her local pharmacy for 3 generic drugs and 1 brand name drug.

The hospital admission charge was $200, and her hospital bill was $34,560.

What amount did she pay?

Example 1 (cont.)Example 1 (cont.)

Find the deductible.

The deductible is $1000.

Example 1 Answer: Example 1 Answer: Step 1Step 1

Find the cost of the co-payments.

Physician + Specialists + Physical Therapy +Pharmacy

($20 × 8) + ($30 × 9) + ($85 × 20% x 12) + 3(10)+20 =

$160 + $270 + $204 + $50 = $684

Example 1 Answer: Example 1 Answer: Step 2Step 2

Find the co-insurance amount for home health care. (Note: Co-insurance requires the insurance company to pay 80 percent of the costs and the patient pays 20 percent of the costs.)

$55 × (75 – 50) × 20%

$55 × 25 × 20% = $275

Example 1 Answer: Example 1 Answer: Step 3Step 3

Find the hospital charges. (Note: The patient pays a small percent of the hospital charge, such as 10 percent.)

$34,560 × (100% – 90%) + 200

$34,560 × 10% + $200= $3656

Example 1 Answer: Example 1 Answer: Step 4Step 4

Find the amount paid by patient.

Deductible + Co-payment + Co-insurance + Hospital Amount Charges

$100 + $684 + $3656 = $5340

Example 1 Answer: Example 1 Answer: Step 5Step 5

Refer to Figure 11.1 on page 421 of your textbook.

Leonard SmallsFamily plan, Non-networkCo-payments: 22 physician visits;12 specialist visits; 25 physical therapy visits at $55 each; 1 ER visit; hospital charge of $15,600

Find the deductible, co-payment, co-insurance, hospital charges, and total paid by the patient.

Practice 1Practice 1

Deductible: $4,500

Co-payment: 22(30) + 12(40) +100 = $1240

Hospital co-insurance: 15600(.3) = $4,680

Co-insurance: 25(55)(.3) = $412.50

Total paid: $10,832.50

Practice 1 AnswerPractice 1 Answer