Preventive care/screening/immunization No charge 40\% coinsurance You 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 $ [__] .
| Preventive care/screening/immunization | No charge | 40\% coinsurance | You 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. |