In-network and not yet met their $500 deductible. The patient has 85% co-insurance. The doctor performs an adjustment and 2 units of therapeutic exercise. The allowed adjustment amount is $35 and the allowed amount for therapeutic exercise is $45. What amount does the patient pay out of pocket?

In-network and not yet met their $500 deductible. The patient has 85% co-insurance. The doctor performs an adjustment and 2 units of therapeutic exercise. The allowed adjustment amount is $35 and the allowed amount for therapeutic exercise is $45. What amount does the patient pay out of pocket?

• A. $35
• B. $125
• C. $25
• D. $100

Answer: (B)

When a patient hasn’t met their deductible, the insurance doesn’t share the cost yet, even if coinsurance exists. The patient is responsible for the full allowed charges until the deductible is satisfied. Here, the total allowed amounts are 35 for the adjustment plus 2 units of therapeutic exercise at 45 each, which is 35 + (2 × 45) = 125. Since the deductible of 500 isn’t met, the patient pays the entire 125 out of pocket. After the deductible is met, coinsurance would apply to remaining charges, but not before.

When a patient hasn’t met their deductible, the insurance doesn’t share the cost yet, even if coinsurance exists. The patient is responsible for the full allowed charges until the deductible is satisfied. Here, the total allowed amounts are 35 for the adjustment plus 2 units of therapeutic exercise at 45 each, which is 35 + (2 × 45) = 125. Since the deductible of 500 isn’t met, the patient pays the entire 125 out of pocket. After the deductible is met, coinsurance would apply to remaining charges, but not before.