Overview
Reflect on the major concepts of the healthcare economy and how this impacts the structures, activities, and providers in healthcare systems. Consider how the complexity of the healthcare system is a major determinant of who gets access to affordable, high-quality, and effective health care. Part of navigating this complexity requires that social workers and other health navigators understand how to interpret health insurance terms to help patients calculate costs.
Review the different guides for interpreting a summary of benefits document found in Module 2: Additional Resources. Then, draw on these resources to review the sample health insurance plan available here: Sample Health Insurance Plan. Using this health insurance plan, you will calculate the total costs for a patient based on one of three scenarios.
First, based on your last name review which case study you will review. Then, use the Coverage Examples document to calculate the costs that each person would pay, and briefly describe these numbers and how you calculated them. Your total calculation should consider: deductibles, copayments, coinsurance, and limits or exclusions.
By the first few letters of your last name:
Ba - Ja: Peg is having a baby
Jo - Oro: Managing Joe's Type 2 diabetes. Select this one
Ort-Ug: Mia's simple fracture
Select two other persons who had a different case study then you. Compare the various costs (deductibles, copayments, coinsurance, limits or exclusions) associated with one case study relative to the other. Which condition is more expensive to manage? Discuss considerations of how these costs might influence health-seeking behaviors of persons with one or more of these conditions.
Peer discussion post
Peg is Having a Baby
Total Cost = $12,700
Deductible = $500
Specialist copayment = $50
Coinsurance - 20%
Peg received 9 months of in-network pre-natal care, coming out to 9 specialist office visits; she also had one visit with an anesthesiologist. The total she paid in copayments for specialist visits thus comes out to $500: (10 specialist visits X $50 copay/visit = $500)
She received diagnostic tests as well, specifically ultrasounds and bloodwork. According to the SBC, in-network diagnostic tests require a $10 copay/test. Though frequency varies, blood work is typically taken three times throughout one's pregnancy and ultrasounds twice. Using these numbers, we can assume that Peg paid $50 in copayments for diagnostic tests: (5 total tests X $10 copay/test = $50)
A coinsurance of 20% is applied to both childbirth/delivery professional services and childbirth/delivery facility services, the remaining two services Peg received. We can calculate what she must pay for these services by first subtracting the $500 deductible from the total cost ($12,700 - $500), which leaves us with $12,200. Then, for each service we can take 20% of $12,200 and multiply the product times two to account for both services: ($12,200 X 0.20 = $2,440) ==> ($2,440 X 2 = $4,880).
Total of what Peg would pay = $500 deductible + $500 specialist copayment total + $50 diagnostic test copayment total + $4,880 coinsurance = $5,930
Theoretically, Peg would pay $5,930. However, this takes her far past her out-of-pocket limit of $2,500 (her deductible of $500 indicates that she is on an individual plan). The SBC plan does not specify which copayments do not count toward the out-of-pocket limit, so I will assume that the aforementioned copayments do not count. This means that Peg will ultimately pay the $550 in cumulative copayments in addition to the $2,500 out-of-pocket limit ($550 + $2,500), which comes out to $3,050.
To summarize, Peg will pay $3,050 and her insurance will pay $9,650.
An limit/exclusion would be prescription drugs; she would have to pay out of pocket up to the specific $300 deductible before her plan starts to pay for them.
Second peer discussion post
Mia’s simple fracture
Deductible = $500
Copay = $50
Coinsurance = $460
First subtract deductible from the total cost ($2,800- $500 = $2,300). With that $2,300 will take the coinsurance which is 20% which gives us $460 ( $2,300 x .20 = $460). Adding the deductible ($500) + copayment ($50) + coinsurance ($460) = $1,010 which is the total Mia would pay out of pocket.
The insurance would be the difference which would be determined by subtracting $1,010 (out of pocket) from $2,800 (total cost) which equals to $1,790 that the insurance will cover.
Mias' visit to the emergency room is in-network as well as her follow up care. The services that Mia had were emergency room care which induced medical supplies, diagnostics (x-rays), DME (crutches) and rehabilitation services (PT).
The exclusions could be the ambulance ride/services and medication.