# 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

\$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

\$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

\$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