Mark, age 28, is insured under an individual medical expense policy that is part of a preferred provider organization (PPO) network. The policy has a calendar-year deductible of $1000, 75/25 percent coinsurance, and an annual out-of-pocket limit of $2000. Mark recently had outpatient arthroscopic surgery on his knee, which he injured in a skiing accident. The surgery was performed in an outpatient surgical center. Mark incurred the following medical expenses. (Assume that the charges shown are the charges approved by Mark’s insurer and that all providers are in the PPO network.)
Outpatient X-rays and diagnostic tests $800
Covered charges in the surgical center $12,000
Surgeon’s fee $3000
Outpatient prescription drugs $400
Physical therapy expenses $1200
In addition, Mark could not work for two weeks and lost $2000 in earnings.
a. Based on the above information, how much of the expenses will be paid by the insurance company?
b. How much of the expenses will Mark have to pay? Explain your answer.
c. Assume that a surgeon who is not in the PPO network actually performed the surgery. Will Mark’s policy cover this fee? Explain your answer.
A. Lotal is $17,400. Must pay $1000 deductible + 25% of exceeding deductible up to out of pocket limit, mark pays $2000+$1000. Insurer pays $14,400
B. $2000+$1000 because policy does not cover loss of earnings
C. Yes, Careoutside the network is covered. Policyholder must pay substantially high deductible and coinsurance charge
Mark, age 28, is insured under an individual medical expense policy that is part of a...
Santiago Morgan is insured under a major medical expense insurance policy that includes a $200 calendar year deductible and a 20 percent coinsurance requirement from the insured. During the last year, Mr. Morgan incurred $1,000 in allowable medical expenses. Of this amount, Mr. Morgan is responsible for paying $640.00 $200.00 $160.00 $360.00
Case 5 Twin Falls Community Hospital (Capital Investment Analysis) Twin Falls Community Hospital is a 250-bed, not-for-profit hospital located in the city of Twin Falls, the largest city in Idaho’s Magic Valley region and the seventh largest in the state. The hospital was founded in 1972 and today is acknowledged to be one of the leading healthcare providers in the area. Twin Falls’ management is currently evaluating a proposed ambulatory (outpatient) surgery center. Over 80 percent of all outpatient surgery...
Gleim 6 Deductions from AGI [1] Which one of the following expenses does not qualify as a deductible medical expense? A. Cost of long-term care for a developmentally disabled person in a relative’s home. B. Special school for a deaf child to learn lip reading. C. Cost of elevator installed for individual who had heart bypass surgery (in excess of increase in value of individual’s home). D. Cost and care of guide dogs used by a blind person in his...