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Example Benefit Calculations

Remember: anything not paid by CINICO is solely the responsibility of the patient.

Mr. X visits Dr. Z at the George Town Hospital. During this visit, Mr. X receives the following treatment and CINICO pays the following benefit:

Procedure	Charge	Paid by CINICO
Office Visit	$100.00	$100.00
Lab Work	$45.00	$0.00
Total Charge	$145.00	$100.00

Mrs. Y is in the United States and has a medical emergency. Mrs. Y contacts Care Coordinator within 48 hours of being admitted and gets authorization of services. During this visit, Mrs. Y receives the following treatment and CINICO pays the following benefit:

Procedure	Charge	Paid by CINICO
Emergency Room Charge	$2,800.00	$2,800.00
Anesthesia	$2,200.00	$2,200.00
Standard Surgical Supplies	$3,024.00	$3,024.00
Lab Work	$1,028.00	$1,028.00
Surgeon	$8,000.00	$5,948.00
Total Charge	$17,052.00	$15,000.00 (Plan Emergency Maximum)

Mrs. X visits Dr. Z at a NON-HSA Hospital without approval from the HSA Chief Medical Officer. During this visit, Mrs. X receives the following treatment and CINICO pays the following benefit:

Procedure	Charge	Paid by CINICO
Office Visit	$100.00	$0.00
Lab Work	$45.00	$0.00
Total Charge	$145.00	$0.00

Mr. Y is referred by the C.M.O. for surgery in the United States. Mr. Y contacts the Care Coordinator who arranges their treatment. During this visit, Mr. Y receives the following treatment and CINICO pays the following benefits:

Procedure	Charge	Paid by CINICO
Room & Board	$2450.00	$1960.00 (80% up to a max of $2,500)
Anesthesia	$550.00	$440.00 (80% up to a max of $2,500)
Standard Surgical Supplies	$1156.00	$1156.00
Lab Work	$400.00	$400.00
Surgeon	$2000.00	$2000.00
Total Charge	$6556.00	$5956.00

Last Updated: 2009-12-16