Billing Examples - HCRA
The following billing examples reflect a surcharge percentage of 8.85%. 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 × 1.0885 = $1,632.75
$1,632.75 ÷ 1.0885 = $1,500.00 (paid by the Plan to the service provider)
$1,632.75 - $1,500.00 = $132.75 (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 × 1.0885 = $1,632.75
$1,632.75 - $200 = $1,432.75 ($200 paid by the participant to the service provider)
$1,432.75 ÷ 1.0885 = $1,316.26 (paid by the Plan to the service provider)
$1,432.75 - $1,316.26 = $116.49 (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 ÷ 1.0885 = $183.74 (kept by the service provider)
$200.00 - $183.74 = $16.26 (paid by the service provider to the Department's Pool Administrator)
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Provider receives:
$1,316.26 paid by Plan
$183.74 paid by participant
Total = $1,500.00
Pool receives:
$116.49 paid by Plan
$16.26 paid by service provider
Total = $132.75
Example of 20% patient co-insurance
Regular hospital bill = $1,500
Hospital bill with applicable surcharge amount: $1,500 × 1.0885 = $1,632.75
The participant pays the service provider 20% ($326.55) and the Plan pays 80% ($1,306.20).
$1,632.75 × .80 = $1,306.20 (80% co-insurance paid by the Plan to the service provider)
$1,306.20 ÷ 1.0885 = $1,200.00 (paid by the Plan to the service provider)
$1,306.20 - $1,200.00 = $106.20 (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.
$1,632.75 × .20 = $326.55 (20% co-insurance paid by the participant to the service provider)
$326.55 ÷ 1.0885 = $300.00 (kept by service provider)
$326.55 - $300.00 = $26.55 (paid by service provider to the Department's Pool Administrator)
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Provider receives:
$1,200.00 paid by Plan
$300.00 paid by participant
$1,500.00 Total
Pool receives:
$106.02 paid by Plan
$26.55 paid by service provider
$132.75 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 × 1.0885 = $1,632.75
Participant pays first $200 (deductible): $1,632.75 - $200 = $1,432.75
Participant responsible for 20% (co-insurance) or $286.55 ($1,432.75 × .20)
Plan responsible for 80% (co-insurance) or $1,146.20 ($1,432.75 × .80)
Plan responsible for paying:
($1,632.75 - $200) × .80 = $1,146.20 ($200 co-payment or deductible paid by the participant to the service provider)
$1,146.20 ÷ 1.0885 = $1,053.01 (paid by Plan to service provider)
$1,146.20 - $1,053.01 = $93.19 (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: $286.55 (paid by participant to service provider)
TOTAL $486.55
Provider (i.e., hospital) responsible for:
$486.55 ÷ 1.0885 = $446.99 (kept by provider)
$486.55 - $446.99 = $39.56 (paid by provider to Department's Pool Administrator)
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Provider receives:
$1,053.01 paid by Plan
$446.99 paid by participant
$1,500.00 Total
Pool receives:
$93.19 paid by Plan
$39.56 paid by provider
$132.75 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 × 1.0885 = $1,632.75
Plan responsible for (payment of maximum benefit):
$500.00 ÷ 1.0885 = $459.35 (paid by the Plan to the service provider)
$500.00 - $459.35 = $40.65 (paid by the Plan to the Department's Pool Administrator)
Participant responsible for (paying provider):
$1,132.75 (paid by the participant to the service provider)
Service provider responsible for (paying the Department's Pool Administrator):
$1,132.75 ÷ 1.0885 = $1,040.65 (kept by service provider)
$1,132.75 - $1,040.65 = $92.10 (paid by service provider to the Department's Pool Administrator)
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Provider receives:
$459.35 paid by Plan
$1,040.65 paid by participant
$1,500.00 Total
Pool receives:
$40.65 paid by Plan
$92.10 paid by the service provider
$132.75 Total