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2010_journal

Dependent care

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BOB

CAROL

TED

ALICE

2010	Medical Claim Tracking Journal			for
		Print this Page			Currency:
MEDICAL	deductible per individual:	$	per family:	$		F S Account
		Total Bills	Amts to Deductible	Medical Plan Total Benefits	Out of pocket Final Costs	Reimbursements
BOB		$4267.00	$300.00	$3276.30	$990.70	$953.20
CAROL		$1862.00	$300.00	$1471.78	$390.22	$203.07
TED		$58.00	$0.00	$43.00	$15.00	$0.00
ALICE		$394.00	$0.00	$53.00	$341.00	$341.00
	Family MEDICAL totals:	$6581.00	$600.00	$4844.08	$1736.92	$1497.27

DRUGS	deductible per individual:	$	per family:	$		F S Account
		Total Bills	Amts to Deductible	Drug Plan Total Benefits	Out of pocket Final Costs	Reimbursements
BOB		$98.25	$0.00	$98.25	$0.00	$0.00
CAROL		$851.95	$0.00	$746.43	$105.52	$105.52
TED		$0.00	$0.00	$0.00	$0.00	$0.00
ALICE		$97.47	$0.00	$97.47	$0.00	$0.00
	Family DRUGS totals:	$1047.67	$0.00	$942.15	$105.52	$105.52

DENTAL	deductible per individual:	$	per family:	$		F S Account
		Total Bills	Amts to Deductible	Dental Plan Total Benefits	Out of pocket Final Costs	Reimbursements
BOB		$202.00	$0.00	$187.00	$15.00	$5.00
CAROL		$390.00	$75.00	$279.00	$111.00	$101.00
TED		$167.00	$0.00	$152.00	$15.00	$5.00
ALICE		$1727.00	$75.00	$406.50	$1320.50	$1286.21
	Family DENTAL totals:	$2486.00	$150.00	$1024.50	$1461.50	$1397.21

Family MED + DRUG + DENT Grand Totals:		$10114.67	$750.00	$6810.73	$3303.94	$3000.00
Family DEPENDENT CARE Totals:		$100.00			$100.00	$0.00

FSA ACCOUNT FOR THE YEAR =		$	TOTAL TO BE WITHHELD FROM PAY=			$
(Pre-Tax "FLEXIBLE SPENDING ACCOUNT")		$3403.94	REIMBURSABLE	/	REIMBURSED	$3000.00
		$	TOTAL FSA AVAILABLE =			$

PREMIUMS			per payment	no. payments/yr	premium/yr
Medical Plan:		premium=	$		$
Drug Plan:		premium=	$		$
Dental Plan:		premium=	$		$
					$	TOTAL PREMIUMS

Notes:

PROCEDURE....................PPO PROVIDER BENEFITS...................................NON-PPO PROVIDER BENEFITS
phys visit.............................$15 copay, 100% coinsurance, no deductible.....60% coinsurance, subj to deduct
phys exam..........................$15 copay, 100% coinsurance, no deductible.....60% coins, not subj to deductible
pap, mamm.......................(same), Dr. must use well code.............................60% coins, not subj to deductible
xray, lab - physician...........$15 copay, 100% coins, no deductible.................60% coinsurance, subj to deduct
xray, lab - outpatient...........80% coins, subj to deductible................................60% coinsurance, subj to deduct
chiropractic..........................50% coins, subj to deductible................................50% coins, subj to deductible
most other............................80% coins, subj to deductible................................60% coinsurance, subj to deduct

out of pkt maximum............$2000 indiv, $3000 family + deductibles..............$4000 indiv, $6000 family + ded

TOTAL UNDISCOUNTED CHARGES BY THE PROVIDERS

INCLUDES ANY DISCOUNTS, AND PAYMENTS

INCLUDES ANY CO-PAYS, AND NON-COVERED CHARGES

AMOUNTS WHICH HAVE BEEN REIMBURSED TO THE CUSTOMER

Flexible Spending Account - paid with pre-tax money

Equals total out-of-pocket costs to date for medical, drug, dental and dependent care.

Equals the total FSA reimbursement to date.

Remaining in FSA Account for further reimbursement.