**Co-Insurance:**

This is a part of the allowed amount, which the carrier has determined that the supplementary insurance or the patient is responsible to pay. This will be mentioned clearly in the EOB and should be billed to the secondary carrier or to the patient.

You will pay a small co-insurance payment if you use inpatient respite care for hospice patients.

** Coinsurance – Means the subscriber’s share of the costs.

› Usually calculated as a percentage of the cost of the medical service.

› Coinsurance for an out-of-network provider is usually a higher percentage than coinsurance for an in-network provider.

› Medicare has per-day coinsurance for Part A and percentage coinsurance for Part B.

› Coinsurance is a payment in addition to any deductibles the subscriber pays.

** Coordination of benefits/third party liability (TPL) amount – Means the amount due from a secondary carrier, when known.

**OPPS Coinsurance**

**OPPS freezes coinsurance for outpatient hospital at 20 percent of the national median charge** for the services within each APC (wage adjusted for the provider’s geographic area), but coinsurance for an APC cannot be less than 20 percent of the APC payment rate. As the total payment to the provider increases each year based on market basket updates, the present or frozen coinsurance amount will become a smaller portion of the total payment until coinsurance represents 20 percent of the total payment. Once coinsurance becomes 20 percent of the payment amount, the annual updates will also increase coinsurance so that it continues to account for 20 percent of the total payment.

**Coinsurance –** A form of medical cost sharing in a health insurance plan that requires an insured person to pay a stated percentage of medical expenses after the deductible amount, if any, was paid.

Once any deductible amount and coinsurance are paid, the insurer is responsible for the rest of the reimbursement for covered benefits up to allowed charges: the individual could also be responsible for any charges in excess of what the insurer determines to be “usual, customary and reasonable”.

Coinsurance rates may differ if services are received from an approved provider (i.e., a provider with whom the insurer has a contract or an agreement specifying payment levels and other contract requirements) or if received by providers not on the approved list.

In addition to overall coinsurance rates, rates may also differ for different types of services.

Coinsurance is the percentage of services that are your financial responsibly. For network benifi ts, your coinsurance amount is 20% for services like lab or x-ray performed outside the doctor’s o ce, outpatient care or inpatient care. The 20% coinsurance you pay during a calendar year accumulates toward your out-of-pocket maximum. The out-of-pocket maximum limits your out-of-pocket costs in a calendar year.

Coinsurance The cost sharing of allowable charges by us and you for covered services after you’ve met your deductible, if applicable. Usually shown as a percentage.

Other Liability Out-of-network costs, costs for services that should have had prior review or authorization before they were performed, or any excluded services.

**What is an out-of-pocket maximum?**

First, an out-of-pocket maximum is not a deductible. The out-of-pocket maximum is the maximum amount you will pay in coinsurance per calendar year. For network benifi ts, the out-of-pocket maximum is $1,000 per person per calendar year. This means that if you have paid $1,000 of coinsurance, for the remainder of that calendar year, HealthSelect will pay 100% for services that typically require you to pay coinsurance (ie., 20%).

**Calculating the Medicare Payment Amount and Coinsurance**

A program payment percentage is calculated for each APC by subtracting the unadjusted national coinsurance amount for the APC from the unadjusted payment rate and dividing the result by the unadjusted payment rate. The payment rate for each APC group is the basis for determining the total payment (subject to wage-index adjustment) that a hospital will receive from the beneficiary and the Medicare program. (A hospital that elects to reduce coinsurance, as described in §30.1, above, may receive a total payment that is less than the APC payment rate.) The Medicare payment amount takes into account the wage index adjustment and the beneficiary deductible and coinsurance amounts. In addition, the amount calculated for an APC group applies to all the services that are classified within that APC group. The Medicare payment amount for a specific service classified within an APC group under OPPS is calculated as follows:

Step 1 – Apply the appropriate wage index adjustment to the payment rate that is set annually for each APC group;

Step 2 – Subtract from the adjusted APC payment rate the amount of any applicable deductible;

Step 3 – Multiply the adjusted APC payment rate, from which the applicable deductible has been subtracted, by the program payment percentage determined for the APC group or 80 percent, whichever is lower. This amount is the preliminary Medicare payment amount;

Step 4 – Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less the amount of any applicable deductible. If the resulting amount does not exceed the annual hospital inpatient deductible amount for the calendar year, the resulting amount is the beneficiary coinsurance amount. If the resulting amount exceeds the annual inpatient hospital deductible amount, the beneficiary coinsurance amount is limited to the inpatient hospital deductible and the Medicare program pays the difference to the provider.

Step 5 – If the wage-index adjusted coinsurance amount for the APC is reduced because it exceeds the inpatient deductible amount for the calendar year, add the amount of this reduction to the amount determined in Step 3 above to get the final Medicare payment amount.

**EXAMPLE 1:**

The wage-adjusted payment rate for an APC is $300; the program payment percentage for the APC group is 70 percent; the wage-adjusted coinsurance amount for the APC group is $90; and the beneficiary has not yet satisfied any portion of his or her $100 annual Part B deductible.

A. Adjusted APC payment rate: $300.

B. Subtract the applicable deductible: $300 – $100 = $200.

C. Multiply the remainder by the program payment percentage to determine the preliminary

Medicare payment amount: 0.7 x $200 = $140.

D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less any unmet deductible to determine the coinsurance amount, which cannot exceed the inpatient hospital deductible for the calendar year: $200 – $140 = $60.

E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation. $140 + $0 = $140.

In this case, the beneficiary pays a deductible of $100 and a $60 coinsurance, and the program pays $140, for a total payment to the provider of $300. Applying the program payment percentage ensures that the program and the beneficiary pay the same proportion of payment that they would have paid if no deductible were taken.

If the annual Part B deductible has already been satisfied, the calculation is as follows:

A. Adjusted APC payment rate: $300.

B. Subtract the applicable deductible: $300 – 0 = $300.

C. Multiply the remainder by the program payment percentage to determine the preliminary

Medicare payment amount: 0.7 x $300 = $210.

D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less deductible to determine the coinsurance amount. The coinsurance amount cannot exceed the amount of the inpatient hospital deductible for the calendar year: $300 – $210 = $90.

E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation: $210 + $0 = $210.

**In this case, the beneficiary makes a $90 coinsurance payment and the program pays $210, for a total payment to the provider of $300.**

**EXAMPLE 2:**

This example illustrates a case in which the inpatient hospital deductible limit on coinsurance amount applies. Assume that the wage-adjusted payment rate for an APC is $2,000; the wage-adjusted coinsurance amount for the APC is $900; the program payment percentage is 55 percent; and the inpatient hospital deductible amount for the calendar year is $776. The beneficiary has not yet satisfied any portion of his or her $100 Part B deductible.

A. Adjusted APC payment rate: $2,000.

B. Subtract the applicable deductible: $2,000 – $100 = $1,900.

C. Multiply the remainder by the program payment percentage to determine the preliminary Medicare payment amount: 0.55 x $1,900 = $1,045.

D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less deductible to determine the coinsurance amount. The coinsurance amount cannot exceed the inpatient hospital deductible amount of $776: $1,900 – $1,045 = $855, but the coinsurance is limited to $776.

E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation ($855 – $776 = $79). $1,045 + $79 = $1,124.

In this case, the beneficiary pays a deductible of $100 and a coinsurance that is limited to $776 and the program pays $1,124 (which includes the amount of the reduction in beneficiary coinsurance due to the inpatient hospital deductible limitation) for a total payment to the provider of $2,000.

For calendar year 2002, the national unadjusted copayment amount for an ambulatory payment classification (APC) is limited to 55 percent of the APC payment rate established for a procedure or service. In addition the wage-adjusted copayment amount for a procedure or service cannot exceed the inpatient hospital deductible amount for 2002 of $812. These changes were implemented by changes to the OPPS Pricer effective for services furnished on or after January 1, 2002.