• Billing Examples

Choosing a provider can impact the amount you pay for covered services.

When selecting a provider you have the choice between a Network Provider (this is a provider that has a contract with your health care plan and will provide services for a set amount that the plan and provider have agreed on, this is referred to as reasonable and customary charges) and an Out of Network provider (this is a provider that does not have a contract with your health care plan and can set there own prices of services that are being rendered).

The amount that your plan is going to pay is based on the agreed upon rate between your provider and the health plan. You may be responsible for cost-sharing amounts, (Deductible, Copay, Coinsurance).

Example 1. In-Network claim payment and advantages over Out of Network

In Network Provider Claim Payment (80% Plan; Deductible is met)
Provider’s billed charge$10,000.00
R&C charges (the maximum amount that can be considered for benefit payment)$8,000.00
The Health Care Plans payment to provider (80% of $8,000)$6,400.00
Member coinsurance (20% of $8,000.00) applied to the out-of-pocket limit-$1,600.0
Amount over the R&C charges, the consumer is responsible for all cost incurred over the R&C charges these amounts do not apply to your out of pocket limits)-$0.00
With coinsurance: the total amount due would be:$1600.00
Total amount due without coinsurance:$0

Example 2. Out of network claim payment and disadvantages of choosing an Out of Network provider.

Example 2. Out of Network Provider Claim Payment (80% Plan; Deductible is met):
Provider’s billed charge$10,000.00
R&C charges (the maximum amount that can be considered for benefit payment)$8,000.00
The Health Care Plans payment to provider (80% of $8,000)$6,400.00
Member coinsurance (20% of $8,000.00) applied to the out-of-pocket limit-$1,600.00
Amount over the R&C charges, the consumer is responsible for all cost incurred over the R&C charges these amounts do not apply to your out of pocket limits)$2,000.00
With coinsurance: the total amount due would be:$3,600.00
Total amount due without coinsurance:$2,000.00
Example 3In-Network Hospital(Plan Pays 90%)Out-of-Network Hospital(Plan Pays 70%)
Actual Hospital Charge$10,500$10,500
Amount Recognized by medical plan:$ 6,500(the discounted rate for health plan)$ 8,800 (the Reasonable & Customary charges based on standard charge for that geographic area) Plan does not recognize the $1,700 difference between the actual charge and the R&C
Medical plan pays:90% of the discounted rate: $6,500 x 90% = $5,95070% of the discounted rate: $8,800 x 70% = $6,160
Member pays:10% of the discounted rate: $6,500 x 10% = $65030% of R&C charges ($8,800) plus 100% of the amount over R&C ($1,700): $2,640 + $1,700 = $4,340

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