Question 72

The subscriber has to pay $1,800 towards the $5,000 total.

To determine the amount the subscriber has to pay, we first apply the deductible, then calculate the coinsurance, and finally ensure it does not exceed the out-of-pocket maximum.

A) $5,000

This option is incorrect because it suggests that the subscriber would pay the entire cost of the procedure. However, with a deductible, coinsurance, and an out-of-pocket maximum in place, the total amount payable cannot equal the full procedure cost.

B) $3,000

This option is also incorrect. Although $3,000 is the out-of-pocket maximum, the subscriber's actual payment based on the deductible and coinsurance is lower than this limit. The out-of-pocket maximum only applies if the calculations exceed this amount, which they do not in this case.

C) $1,800

This option is correct. First, the subscriber pays the $1,000 deductible, leaving a remaining balance of $4,000. With an 80/20 coinsurance, the subscriber is responsible for 20% of the remaining cost, which equals $800 (20% of $4,000). Therefore, the total the subscriber pays is $1,000 (deductible) + $800 (coinsurance) = $1,800.

D) $1,000

This option is incorrect because it only considers the deductible payment. While the subscriber does pay this amount initially, they also incur additional costs through coinsurance that must be accounted for, leading to a higher total payment.

Conclusion

The correct answer of $1,800 is reached by properly applying the deductible and coinsurance while considering the structure of the health insurance policy. The other options fail to reflect the correct calculations based on the given insurance terms, either by representing the total cost incorrectly or by neglecting the additional coinsurance responsibilities of the subscriber.