The following billing examples reflect a surcharge percentage of 9.63%. Refer to Payor Surcharge Rates for current and historical surcharge rates.
Note: These examples assume a private payor has elected to directly pay the Department of Health Pool Administrator and assumes a bill of $1,500.00.
Example 1: Plan paying entire bill
Regular hospital bill = $1,500
Hospital bill with applicable surcharge amount: $1,500 × 1.0963 = $1,644.45
$1,644.45 ÷ 1.0963 = $1,500.00 (paid by the Plan to the service provider)
$1,644.45 - $1,500.00 = $144.45 (paid by the Plan to the Department´s Pool Administrator)
Example 2: $200 patient co-payment or deductible
Regular hospital bill = $1,500
Hospital bill with applicable surcharge amount: $1,500 × 1.0963 = $1,644.45
$1,644.45 - $200 = $1,444.45 ($200 paid by the participant to the service provider)
$1,444.45 ÷ 1.0963 = $1,317.57 (paid by the Plan to the service provider)
$1,444.45 - $1,317.57 = $126.88 (paid by the Plan to the Department´s Pool Administrator)
Upon receipt of the $200 co-payment from the participant, the service provider uses the same formula.
$200.00 ÷ 1.0963 = $182.43 (kept by the service provider)
$200.00 - $182.43 = $17.57 (paid by the service provider to the Department´s Pool Administrator)
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Provider keeps:
$1,317.57 paid by Plan
$182.43 paid by participant
Total = $1,500.00
Pool receives:
$126.88 paid by Plan
$17.57 paid by service provider
Total = $144.45
Example 3: 20% patient co-insurance
Regular hospital bill = $1,500
Hospital bill with applicable surcharge amount: $1,500 × 1.0963 = $1,644.45
The participant pays the service provider 20% ($328.89) and the Plan pays 80% ($1,315.56).
$1,644.45 × .80 = $1,315.56; (total paid by plan to service provider and Pool Administrator-see breakdown below).
$1,315.56 ÷ $1,200.00 (80% co-insurance paid by the Plan to the service provider)
$1,315.56 - $1,200.00 = $115.56 (paid by the Plan to the Department´s Pool Administrator)
Upon receipt of the 20% from the participant, the service provider uses the same formula.
$1,644.45 × .20 = $328.89 (20% co-insurance paid by the participant to the service provider)
$328.89 ÷ 1.0963 = $300.00 (kept by service provider)
$328.89 - $300.00 = $28.89 (paid by service provider to the Department´s Pool Administrator)
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Provider keeps:
$1,200.00 paid by Plan
$300.00 paid by participant
$1,500.00 Total
Pool receives:
$115.56 paid by Plan
$28.89 paid by service provider
$144.45 Total
Example 4: $200 patient co-payment or deductible and 20% patient co-insurance
Regular hospital bill = $1,500
Hospital bill with applicable surcharge amount: $1,500 × 1.0963 = $1,644.45
Participant pays first $200 (deductible): $1,644.45 - $200 = $1,444.45
Participant responsible for 20% (co-insurance) or $288.89 ($1,444.45 × .20)
Plan responsible for 80% (co-insurance) or $1,155.56 ($1,444.45 × .80)
Plan responsible for paying:
($1,644.45 - $200) × .80 = $1,155.56 ($200 co-payment or deductible paid by the participant to the service provider)
$1,155.56 ÷ 1.0963 = $1,054.05 (paid by Plan to service provider)
$1,155.56 - $1,054.05 = $101.51 (paid by Plan to the Department´s Pool Administrator)
Participant responsible for paying:
Deductible: $200.00 (paid by participant to service provider)
20% Co-insurance: $288.89 (paid by participant to service provider)
Total $488.89
Provider (i.e., hospital) responsible for:
$488.89 ÷ 1.0963 = $445.95 (kept by provider)
$488.89 - $445.95 = $42.94 (paid by provider to Department´s Pool Administrator)
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Provider keeps:
$1,054.05 paid by Plan
$445.95 paid by participant
$1,500.00 Total
Pool receives:
$101.51 paid by Plan
$42.94 paid by provider
$144.45 Total
Example 5: Plan providing full payment up to a maximum benefit of $500.00
Regular hospital bill = $1,500
Hospital bill with applicable surcharge amount: $1,500 × 1.0963 = $1,644.45
Plan responsible for (payment of maximum benefit):
$500.00 ÷ 1.0963 = $456.08 (paid by the Plan to the service provider)
$500.00 - $456.08 = $43.92 (paid by the Plan to the Department´s Pool Administrator)
Participant responsible for (paying provider):
$1,144.45 (paid by the participant to the service provider)
Service provider responsible for (paying the Department´s Pool Administrator):
$1,144.45 ÷ 1.0963 = $1,043.92 (kept by service provider)
$1,144,45 - $1,043.92 = $100.53 (paid by service provider to the Department´s Pool Administrator)
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Provider keeps:
$456.08 paid by Plann
$1,043.92 paid by participant
$1,500.00 Total
Pool receives:
$43.92 paid by Plan
$100.53 paid by the service provider
$144.45 Total