What are the Outpatient services (physician / surgeon fees) if the cost of the service is $20,000?
Given that it was paid for the hospitalization facility fee, it should not appear in the calculation for outpatient services. For that calculation, you have to be mindful of the out-of-pocket maximum.
According to covered California website the plan, Sharp Silver 70 HMO Performance plan in 2020, the following applies to Susan
- Zip code: 92101
- Household income: $80,000
- People in household: 1
- Age 55
Medical deductible for an individual with this policy $4,000
Pharmacy deductible for an individual with this policy $300
Out-of-pocket maximum for an individual with this policy $7,800
Monthly premium for Susan with the Sharp Silver 70 HMO Performance plan is $780.48
(Coinsurance of 20%)
calculations for partial credit. Hospitalization facility fee Deductible = 4000 $11,50 Coinsurance .20 0 11,500-4000=1,500+4000=5,500 Amount: $5,500 (0.5 points) $60 individual visit $300 deductible Tier 2 preferred brand-name drug (30-day supply) $150 Amount: $150 (0.5 points) $85/ visit X-ray (radiology services in Professional services) $300 Amount: $85 (0.5 points) $40/ visit Primary Care Physician office visit for consultation $200 Amount: $40 (0.5 points) $20,00 Outpatient services (physician/ surgeon fees) 0 Amount: (0.5 points) $325 per procedure MRI (Advanced radiology in Professional Services) $1,500 Amount: $325 (0.5 points) Total cost sharing 22,100 (0.25 points) + Annual 780.48*12= $9,365.76 (0.25 points) premiums Summary of Benefits SO SO Covered California Sharp Silver 70 Performance HMO THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS, PLEASE CONTACT YOUR EMPLOYER FOR SPECIFIC INFORMATION ON YOUR COVERAGE OR VISIT WWW.SHARPHEALTHPLAN.COM TO VIEW THE MEMBER HANDBOOK Covered Benefits Copayments Annual Deductible for Specific Services' Calendar year medical deductible (per individual/per family) - applies only to those covered benefits indicated $4,000 / $8,000 Calendar year pharmacy deductible (per individual/per family) - applies to Tier 1, Tier 2, Tier 3, and Tier 4 $300 / $600 Calendar year dental deductible (per individual/per family) $0 / $0 Annual Out of Pocket Maximum Annual out of pocket maximum (per individual/per family) $7,800 / $15,600 Lifetime Maximum There are no lifetime maximums for this plan Unlimited Preventive Care Well-baby and well-child to age 18) physical exams, immunizations and related laboratory services $0 Routine adult physical exams, immunizations and related laboratory services $0 Laboratory, radiology and other services for the early detection of disease when ordered by a Physician $0 Routine gynecological exams, immunizations and related laboratory services $0 Mammography Prostate cancer screening $0 Colorectal cancer screenings including sigmoidoscopy and colonoscopy $0 Best Health Wellness Services On-line health education and wellness workshops and other wellness tools $0 Telephonic health coaching (weight management, tobacco cessation, stress management, physical activity, nutrition) Professional Services Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $40 / visit Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $80 / visit Other Practitioner office visit, including acupuncture $40 / visit Laboratory tests and services $40 / visit Radiology services (X-rays and diagnostic imaging) $85 / visit Advanced radiology (including but not limited to CT/PET scan, MRI, MRA, MRS, MUGA, SPECT) $325 / procedure Allergy testing $80 / visit Allergy injections $80 / visit Outpatient Services (including but not limited to surgical, diagnostic and therapeutic services) Outpatient surgery facility fee 20% coinsurance Physician/Surgeon fees 20% coinsurance Outpatient visit 20% coinsurance Infusion therapy (including but not limited to chemotherapy) 20% coinsurance Dialysis 20% coinsurance Rehabilitation services: physical, occupational and speech therapy $40 / visit Habilitation services $40 / visit Radiation therapy 20% coinsurance Hospitalization (including but not limited to inpatient services, organ transplant, and inpatient rehabilitation) Facility fee 20% coinsurance Physician/surgeon fee 20% coinsurance Emergency and Urgent Care Services Emergency room facility fee (waived if admitted to the hospital) $400 / visit $0 Emergency room physician fee (waived if admitted to the hospital) Urgent care services $40 / visit Medical Transportation Emergency medical transportation $250 Non-emergency medical transportation $250 calculations for partial credit. Hospitalization facility fee Deductible = 4000 $11,50 Coinsurance .20 0 11,500-4000=1,500+4000=5,500 Amount: $5,500 (0.5 points) $60 individual visit $300 deductible Tier 2 preferred brand-name drug (30-day supply) $150 Amount: $150 (0.5 points) $85/ visit X-ray (radiology services in Professional services) $300 Amount: $85 (0.5 points) $40/ visit Primary Care Physician office visit for consultation $200 Amount: $40 (0.5 points) $20,00 Outpatient services (physician/ surgeon fees) 0 Amount: (0.5 points) $325 per procedure MRI (Advanced radiology in Professional Services) $1,500 Amount: $325 (0.5 points) Total cost sharing 22,100 (0.25 points) + Annual 780.48*12= $9,365.76 (0.25 points) premiums Summary of Benefits SO SO Covered California Sharp Silver 70 Performance HMO THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS, PLEASE CONTACT YOUR EMPLOYER FOR SPECIFIC INFORMATION ON YOUR COVERAGE OR VISIT WWW.SHARPHEALTHPLAN.COM TO VIEW THE MEMBER HANDBOOK Covered Benefits Copayments Annual Deductible for Specific Services' Calendar year medical deductible (per individual/per family) - applies only to those covered benefits indicated $4,000 / $8,000 Calendar year pharmacy deductible (per individual/per family) - applies to Tier 1, Tier 2, Tier 3, and Tier 4 $300 / $600 Calendar year dental deductible (per individual/per family) $0 / $0 Annual Out of Pocket Maximum Annual out of pocket maximum (per individual/per family) $7,800 / $15,600 Lifetime Maximum There are no lifetime maximums for this plan Unlimited Preventive Care Well-baby and well-child to age 18) physical exams, immunizations and related laboratory services $0 Routine adult physical exams, immunizations and related laboratory services $0 Laboratory, radiology and other services for the early detection of disease when ordered by a Physician $0 Routine gynecological exams, immunizations and related laboratory services $0 Mammography Prostate cancer screening $0 Colorectal cancer screenings including sigmoidoscopy and colonoscopy $0 Best Health Wellness Services On-line health education and wellness workshops and other wellness tools $0 Telephonic health coaching (weight management, tobacco cessation, stress management, physical activity, nutrition) Professional Services Primary Care Physician office visit for consultation, treatment, diagnostic testing, etc. $40 / visit Specialist Physician office visit for consultation, treatment, diagnostic testing, etc. $80 / visit Other Practitioner office visit, including acupuncture $40 / visit Laboratory tests and services $40 / visit Radiology services (X-rays and diagnostic imaging) $85 / visit Advanced radiology (including but not limited to CT/PET scan, MRI, MRA, MRS, MUGA, SPECT) $325 / procedure Allergy testing $80 / visit Allergy injections $80 / visit Outpatient Services (including but not limited to surgical, diagnostic and therapeutic services) Outpatient surgery facility fee 20% coinsurance Physician/Surgeon fees 20% coinsurance Outpatient visit 20% coinsurance Infusion therapy (including but not limited to chemotherapy) 20% coinsurance Dialysis 20% coinsurance Rehabilitation services: physical, occupational and speech therapy $40 / visit Habilitation services $40 / visit Radiation therapy 20% coinsurance Hospitalization (including but not limited to inpatient services, organ transplant, and inpatient rehabilitation) Facility fee 20% coinsurance Physician/surgeon fee 20% coinsurance Emergency and Urgent Care Services Emergency room facility fee (waived if admitted to the hospital) $400 / visit $0 Emergency room physician fee (waived if admitted to the hospital) Urgent care services $40 / visit Medical Transportation Emergency medical transportation $250 Non-emergency medical transportation $250
