Billing Examples - HCRA

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 DOH Pool Administrator and assumes a bill of $1,500.00.

Example of 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 of $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)

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 of 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)

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 of $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)

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 of the 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)

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

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