A 46-year-old woman with a history of hypertension and type 2 diabetes mellitus is traveling out of state for work. While out jogging, she slips and falls and fractures her ankle. The patient belongs to an employer-sponsored private health insurance plan which has an annual deductible of $3,000. Prior to this incident, she had paid $3,000 this year to other health care providers for covered health care expenses. The patient visits an in-network urgent care provider, where she receives an x-ray, an injection of pain medication, and a cast on her injured ankle. Three months later, the patient receives a bill from the urgent care facility stating that she owes $1,000 for services rendered. Which of the following is most accurate?

Question

A 46-year-old woman with a history of hypertension and type 2 diabetes mellitus is traveling out of state for work.  While out jogging, she slips and falls and fractures her ankle.  The patient belongs to an employer-sponsored private health insurance plan which has an annual deductible of $3,000.  Prior to this incident, she had paid $3,000 this year to other health care providers for covered health care expenses.  The patient visits an in-network urgent care provider, where she receives an x-ray, an injection of pain medication, and a cast on her injured ankle.  Three months later, the patient receives a bill from the urgent care facility stating that she owes $1,000 for services rendered.  Which of the following is most accurate?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0d1_10d5_8f63_b335cd83b464_MD0005_00 Insured patients' out-of-pocket spending on covered health care services-known as cost-sharing-can vary significantly depending on the insurance plan. Each plan generally requires patients to spend a minimum amount out-of-pocket, known as the deductible, before covering expenses. After meeting the plan deductible, patients may still incur additional cost-sharing for in-network services. Examples of patient cost-sharing include copayments (ie, copays, a fixed amount per service, such as an office visit) and coinsurance (ie, a fixed percentage of the cost of a health care service, such as a hospital stay). In this case, the patient has already met her annual deductible of $3,000 (ie, she paid $3,000 this year to other providers for covered health care services) (Choice D). Her responsibility for the $1,000 urgent care bill depends on her plan's out-of-pocket maximum, describing the patient's annual cost-sharing limit: If her deductible equals her out-of-pocket maximum (eg, both are $3,000), the patient has already reached her maximum cost-sharing limit by meeting the deductible, so her plan would be required to pay 100% of this bill. If her deductible is less than her out-of-pocket maximum (eg, her deductible is $3,000, but her out-of-pocket maximum is $5,000), the patient has not reached the plan's maximum cost-sharing limit yet and would likely have to pay at least part of the bill. For example, the patient may be required to pay co-insurance (eg, a percentage, such as 20%, of the urgent care bill) (Choice A) Workers' compensation (in which employers, not insurance plans, pay for an employee's health care services) may be appropriate if the patient had sustained the injury directly due to her job environment. This patient injured her ankle during a voluntary, recreational activity; therefore, employer payment would be inappropriate. (Choice B) Some insurance plans incentivize patients to seek care at in-network facilities by offering lower copayment or coinsurance rates. However, even with in-network status, the out-of-pocket maximum and cost-sharing responsibilities above the deductible may still apply. Educational objective: Patients must spend an annual deductible (ie, minimum out-of-pocket payment) before insurance begins to cover services. Patients may still incur cost-sharing above the deductible depending on a plan's annual out-of-pocket maximum (ie, maximum limit on patient out-of-pocket spending).

A 46-Year-Old Woman with a History of Hypertension and Type