Description
Chapter 2 discusses aspects of covered services for which the insurance company will pay which are outlined in the healthcare plan/policy. Remember that not all insurance plans are the same.Each plan may require different copays and co-insurance amounts based on whether the patient received services in-network or out-of-network. We will be looking at :Plan B – Magnolia Local Plus The plan also identifies the patient’s portions as well. Pay attention to deductible, copays, coinsurance amounts as well as drug tier benefits. In this assignment, you are provided with excerpts from three different plans.Using the benefits summary table presented for each plan, you will calculate the cost-sharing amount (the amount paid by the patient) for the following scenarios.Pay attention to deductible amounts, copays, coinsurance amounts as well as drug tier benefits. Please show calculations where necessary.2.Inpatient hospital admission, deductible is met Admission to Acadiana General Hospital (in-network) Admission Dates of Service: 6/1/2022-6/4/2022 Diagnosis: O80, Encounter for full-term uncomplicated delivery Allowable Charges = $11,725.00 The amount paid by the patient for the hospital admission would be $________. 3.Urgent care visit, deductible is met Urgent care visit at Madison Urgent Care (out-of-network) Urgent care visit Date of Service: 07/04/2022 Allowable Charges = $275.00 The amount paid by the patient for the visit to the Urgent Care Center would be $_______..4. Outpatient surgery(deductible met) Admission to Park Place Surgical Hospital (network) Admission DOS: 6/1/2022‒6/1/2022 Total reimbursement to Park Place Surgical Hospital: $5,325 The amount paid by the patient for the outpatient hospital surgery would be $___________. 6.Outpatient hospital surgery—surgeon fees(deductible met) Dr. Meishkou (network) Admission DOS: 6/1/2022‒6/1/2022 Total reimbursement to Dr. Meishkou: $1,225 The amount paid by the patient to Dr. Meishkou would be $_________. 7.Cardiologist visit, out-of-network(deductible met) Encounter at Dr. Edwards’ office Visit DOS: 08/04/2022 Total reimbursement to Dr. Edwards: $450 The amount paid by the patient to Dr. Edward’s would be $__________. 8.Pharmacy prescription, preferred brand drug, out-of-network provider Pharmacy at U-Shop Date prescription filled: 8/04/2022 Total reimbursement for U-Shop: $55.00 The amount paid by the patient for the prescription would be $_________.
MAGNOLIA LOCAL PLUS
COPAYMENTS and COINSURANCE
Deductible:
NOTE:
Applicable with co-insurance ONLY.
Copays do not count towards meeting
deductible.
Individual: $400
No Coverage
Individual + 1 dependent:
$800
Individual + 2 or more
dependents: $1,200
NETWORK PROVIDERS
NON-NETWORK PROVIDERS
Physician Office Visits including surgery
performed in an office setting:
• General Practice
• Family Practice
• Internal Medicine
• Midwife
• OB/GYN
• Pediatrics
• Geriatrics
$25.00
Copayment per Visit
No Coverage
Allied Health/Other Professional Visits:
• Chiropractors
• Federally Funded Qualified Rural
Health Clinic
• Nurse Practitioner
• Retail Health Clinic
• Physician Assistant
$25.00
Copayment per Visit
No Coverage
Specialist Office Visits including surgery
performed in an office setting:
• Physician
• Podiatrist
• Optometrist
• Audiologist
• Registered Dietitian
• Sleep Disorder Clinic
$50.00
Copayment per Visit
No Coverage
Ambulatory Surgical Center and Outpatient
Surgical Facility
$100.00 Copayment
No Coverage
Emergency Room (Facility Charge)
$200.00 Copayment; Waived if Admitted
Emergency Medical Services
(Non-Facility Charges)
Inpatient Hospital Admission, All Inpatient
Hospital Services Included
100% – 0%1
100% – 0%1
$100.00 Copayment per
day2, maximum of
$300.00 per Admission
No Coverage
100% – 0%1
No Coverage
Inpatient and Outpatient Professional
Services for Which a Copayment Is
Not Applicable
40HR1608 R01/22
1
Pregnancy Care – Physician Services
$90.00 Copayment per
pregnancy
No Coverage
$50.00 Copayment
No Coverage
Urgent Care Center
Prescription Drug
Generic Name
Brand Name
Specialty
$10 for 30 day supply
$55 for 30 day supply
$80 for 30 day supply
Negotiated rate
Non-Formulary
1Subject to Plan Year Deductible, if applicable
2Pre-Authorization Required, if applicable.
40HR1608 R01/22
2
No Coverage
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