Assume that a surgeon who is not in the PPO network actually performed the surgery. Will James?s policy cover this fee? Explain your answer.

Assume that a surgeon who is not in the PPO network actually performed the surgery. Will James?s policy cover this fee? Explain your answer.

Explain the various definitions of disability that are found in disability-income insurance.
b. Briefly explain the following disability-income insurance provisions: Residual disability, Benefit period, Elimination period, Waiver of premium.

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2. Identify five major provisions of the Affordable Care Act that will have an impact on individuals and families. Document your source and attach a copy of your information.

3. a. Describe the basic characteristics of individual medical insurance.
b. Why are deductibles and coinsurance used in medical expense policies?

4. Briefly explain the major characteristics of a health savings account (HSA).

5. Identify the optional benefits that can be added to a disability-income policy.

6. Explain the following renewal provisions that may appear in individual health insurance policies:
a. Guaranteed renewable
b. Noncancellable
c. Conditionally renewable

7. James, 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. James recently had outpatient arthroscopic surgery on his knee, which he injured in a skiing accident. The surgery was performed in an outpatient surgical center. James incurred the following medical expenses. (Assume that the charges shown are the charges approved my James?s insurer and that all providers are in the PPO network.)

1. Workers compensation laws provide considerable financial protection to workers who have a job-related accident or disease.
a. Explain the fundamental legal principles on which workers compensation laws are based.
b. List the various ways that covered employers can comply with the state?s workers compensation law.
c. Explain the eligibility requirements for collecting workers compensation benefits.

2. What are three basic benefits provided in the OASDI program?

3. The OASDI program provides retirement benefits to covered employees and their dependents. Explain whether each of the following persons would be eligible for OASDI retirement benefits based on the retired worker?s earnings record. Treat each situation separately.
a. A retired worker?s unmarried son, age 25, who became totally disabled at age 15 because of an auto accident.
b. A spouse, age 63, of a retired worker who is no longer caring for an unmarried child under age 18.
c. A retired worker?s spouse, age 45, who is caring for the 12-year-old daughter of the retired worker.
d. A divorced spouse, age 55, who was married to a retired worker for six years.

4. The Original Medicare Plan consists of Hospital Insurance (Medicare Part A) and Medical Insurance (Medicare Part B). For each of the following losses, indicate whether the loss is covered under Medicare Part A or Medicare Part B. (Ignore any deductible or coinsurance requirements. Treat each situation separately.)
a. Jane, age 66, is hospitalized for five days because of a heart attack.
b. Alan, age 62, has prostate cancer and visits his family doctor for treatment.
c. Margaret, age 80, is a patient in a skilled nursing facility. She has been confined to the nursing home for more than two years.
d. Joseph, age 72, has a hearing impairment and obtains a hearing aid from a local firm.
e. Margie, age 68, has a speech impairment and is confined to her home because of a stroke. A licensed speech therapist visits her in the home and provides services to restore her speech.
f. Albert, age 78, has an arthritic hip that makes it painful to walk and needs surgery to have the hip replaced.

5. A critic of state unemployment insurance programs stated that ?unemployment insurance programs are designed to maintain economic security for unemployed workers, but several critical problems must be resolved.?
a. What type of unemployment is covered under a typical state unemployment insurance program?
b. Describe some actions that may disqualify a worker for unemployment benefits.
c. Why is the fraction of unemployed workers who receive unemployment benefits relatively low?

? 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, James 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 James have to pay? Explain your answer.
c. Assume that a surgeon who is not in the PPO network actually performed the surgery. Will James?s policy cover this fee? Explain your answer.


 

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