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Preventive care/screening/immunizationNo charge40\% coinsuranceYou may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.

If you have a test
\begin{tabular}[t]{l}
Diagnostic test (x-ray, blood work)

Imaging (CT/PET scans, MRIs)
&


No charge

No charge
&


40\% coinsurance

40\% coinsurance
&


Network Office diagnostic imaging - no charge.

Network outpatient diagnostic imaging - 20\% coinsurance, deductible does not apply.
\\

\hline If you have outpatient surgery & Facility fee (e.g., ambulatory surgery center) & 20\% coinsurance & 40\% coinsurance & None \\

\hline & Physician/surgeon fees & 20\% coinsurance & 40\% coinsurance & None \\

\hline \multirow{3}{}{If you need immediate medical attention} & Emergency room care & \$100.00 copay/visit & \$100.00 copay/visit & \multirow{3}{}{None} \\

\hline & Emergency medical transportation & 20\% coinsurance & 20\% coinsurance & \\

\hline & Urgent care & \$20.00 copay/visit & 40\% coinsurance & \\

\hline \multirow{2}{*}{If you have a hospital stay} & Facility fee (e.g., hospital room) & 20\% coinsurance & 40\% coinsurance & None \\

\hline & Physician/surgeon fees & 20\% coinsurance & 40\% coinsurance & None \\

\hline

\end{tabular}



Type the correct answer in each box. Round your answers to the nearest whole dollar.



The copay to see a specialist who is a network provider was $ [__] . Her father needed outpatient surgery, and he found a network provider who could help him. After he paid a deductible of $1,000, he paid 20% coinsurance on a surgery that cost $21,000. Therefore, he paid only $ [__] for the surgery. The total amount Gina's dad paid for his care was $ [__] .

Verified Answer :

  • Identify the specialist copay as \(0\) since no copay is listed for network specialist services in the table.
  • Calculate the surgery coinsurance as 20% of the cost remaining after the deductible: \(0.20 \times (\$21,000 - \$1,000) = \$4,000\).
  • Determine the total cost paid as the sum of the deductible and coinsurance: \(1,000 + 4,000 = \$5,000\).
  • The final answers are \(\boxed{\$0}\), \(\boxed{\$4,000}\), and \(\boxed{\$5,000}\).

Explanation

  1. Analyzing the Coverage Table

To determine the costs associated with the medical services, we first analyze the provided coverage table. The insurance plan outlines different coverage rates for various services depending on whether they are considered "No charge" (in-network) or involve "40% coinsurance" (out-of-network). For outpatient surgery, the table specifies a 20% coinsurance for both facility fees and physician/surgeon fees in the "No charge" column. Since the information for a specialist copay is not explicitly listed in the provided table, it is standard practice to conclude that for such a network provider under this plan, the copay is \$0.

  1. Calculating Surgery Costs

Next, we calculate the cost for the outpatient surgery. The total cost of the surgery was \(\$21,000\), and the father paid a deductible of \(\$1,000\). The remaining amount, which is subject to the 20% coinsurance, is calculated as:
\[\text{Remaining amount} = \$21,000 - \$1,000 = \$20,000\]
The coinsurance payment is then 20% of this remaining amount:
\[\text{Coinsurance} = 0.20 \times \$20,000 = \$4,000\]
Thus, the father paid \(\$4,000\) for the surgery coinsurance.

  1. Final Calculation of Costs

Finally, we calculate the total amount the father paid for his care. This is the sum of the deductible and the coinsurance payment:
\[\text{Total Paid} = \text{Deductible} + \text{Coinsurance} = \$1,000 + \$4,000 = \$5,000\]
All calculations were rounded to the nearest whole dollar as required. The final results are:

  • Specialist copay: \(\$0\)
  • Amount paid for surgery (coinsurance): \(\$4,000\)
  • Total amount paid: \(\$5,000\)

Examples

Understanding insurance coverage is crucial for managing personal finances. For example, when planning for a medical procedure, knowing exactly how your insurance deductible and coinsurance work can help you estimate your out-of-pocket expenses. By analyzing the costs of facility fees and physician services as shown here, patients can budget effectively and avoid financial stress when receiving necessary healthcare. In this case, the total cost for the father's surgery was \(1,000 + (21,000 - 1,000) \times 0.20 = \boxed{\$5,000}\).

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