Continuing Case Chapter 9: HEALTH AND DISABILITY INCOME INSURANCE

Jamie Lee and Ross, happy newlyweds with a new home and twins on the way, are anxiously awaiting their new bundles of joy. Ross was understandably nervous as he wondered if everything would go smoothly with Jamie's pregnancy. Fortunately, they coordinated benefits from the medical insurance group plan offered by Ross's employment at the graphics agency and Jamie Lee's own plan, although Ross's plan would be their primary. His employer offers a health care savings plan, but Ross had not previously realized the benefit of participating.

Jamie Lee has had maternity care that she has been comfortable with so far, but Ross needed to review their health insurance policies with the potential of extensive medical expenses just on the horizon. He wondered if his salary would be enough to pay for the expenses that were not covered for out-of-network doctors.

Current Medical Insurance Plan Provisions

Jamie Lee and Ross have a preferred provider organization (PPO) plan.

In-Network Medical Care:

Jamie Lee and Ross currently have a $15 copayment on regular preventative care doctor visits and a $30 copayment on specialists that are preferred providers or participating member from the PPO plan's list.

Out-of-Network Medical Care:

Jamie Lee and Ross have the choice of seeking medical care from professionals of their choice outside the PPO member list, but they will incur a deductible of $500 per person or $1000 per family per year.

After the deductible is met, there is a coinsurance of 80percent/20percent. The insurance company will cover 80 percent of the allowable medical fees, and the policyholders will be responsible for the other 20 percent of the allowable medical fees.

Medical fees that are not allowed under the medical plan provisions would be 100 percent of the policyholders' responsibility.

Out-of-Pocket Limits:

Their health insurance plan provides an out-of-pocket limit of $7,500 per year.

QUESTION:

Jamie Lee and Ross learned that the hospital that they plan to use for the delivery is not a participating hospital. What will their financial responsibility be for the nonparticipating hospital expenses?