Calculating the Coinsurance and Deductible

Question

Use the following information as you answer the following questions.

Patient: Zach Green

Deductible: $750

Coinsurance: 80/20

Patient out-of-pocket expense maximum: $2000

1. During Zach’s first visit of the year, he incurred a $500 bill. Who pays this bill? I believe the answer is "Zach pays the bill." I'm not 100% sure on this though. He hasn't met his deductible so thats why I say Zach is responsible for this bill.

2. During Zach’s second visit of the year, he incurred a $450 bill. Describe how much is paid by Zach and the insurance carrier. I'm not sure how to calculate this. When I did it I got, Zach paid $840.

Answer 1

Hi Christy:

Zach has to pay a total of $790.00 for both visits; his entire $750 deductible + his 20% share of the coinsurance, $40 = $790.00

After Zach's first visit, he pays $500 out-of pocket which is applied to his $750. deductible leaving him with $250 to pay out-of-pocket for his second visit.

After Zach's second visit, he pays $250 out-of-pocket to meet the balance of his deductible leaving 200 to be paid by the insurance company @80% coinsurance = $160.00 so Zach has to pay $40.00 for the second visit.

In total, Zach has to pay $750 to meet his deductible and then an additional $40.00 for his 20% share of the coinsurance for the second visit = $790.00

So Zach pays $790.00 and the insurance company pays $160.00 = $950. total for both visits. If he has any more claims, he will have to up to an additional $1,210 out of pocket to meet his $2,000 out-of-pocket maximum.

Hope this helps!