39. A group major medical policy is written with a $1,000 deductible, 80/20 coinsurance, and an out-of-pocket maximum of $3,000. The total cost of the procedure is $5,000. How much does the subscriber have to pay towards the $5,000 total?
Answer: C
The subscriber has to pay $1,800 towards the $5,000 total.
To determine the amount the subscriber has to pay, we first account for the deductible and then apply the coinsurance to the remaining amount, while ensuring that the out-of-pocket maximum is not exceeded.
A) $5,000
This option is incorrect because it suggests that the subscriber pays the entire cost of the procedure. However, the policy includes a deductible and coinsurance that limit the subscriber's total payment.
B) $3,000
While this option reflects the out-of-pocket maximum, it is incorrect in this scenario. The total payment for the procedure, after accounting for the deductible and coinsurance, results in a lower amount than the maximum.
C) $1,800
This is the correct option. The subscriber first pays the $1,000 deductible. After this, the remaining balance of $4,000 incurs an 80/20 coinsurance, where the subscriber pays 20% of $4,000, which equals $800. Therefore, the total amount the subscriber pays is $1,000 (deductible) + $800 (coinsurance) = $1,800.
D) $1,000
This option is incorrect as it only accounts for the deductible. It does not consider the additional costs incurred after the deductible is met, which are subject to coinsurance.
Conclusion
The correct answer is $1,800, as it accurately reflects the subscriber's total payment after applying the deductible and the coinsurance to the remaining amount. All other options either overestimate or underestimate the subscriber's payment based on the terms of the policy.