Margo, age 35, was severely injured in an auto accident. She is covered under he
ID: 339275 • Letter: M
Question
Margo, age 35, was severely injured in an auto accident. She is covered under her employer's preferred provider organization (PPO) plan. The plan has a $1,000 calendar-year deductible, 80/20 percent coinsurance, and an annual out-of-pocket maximum limit of $3,000. As a result of the accident, Margo incurred the following medical expenses: $500 4,000 S5,000 $300 $1,200 Cost of ambulance to the hospital Hospital bill for a 3-day stay Surgery for broken leg Prescription drugs outside the hospital Physical therapy for the broken leg In addition, Margo could not work for 1 month and lost $4,000 in earnings. a. Based on this information, how much will Margo collect for her injury if she receives medical care from healthcare providers who are part of the PPO network? (Assume that all charges shown are the allowable or approved charges by the insurer and all providers are in the PPO b. Assume that Margo's broken leg does not heal properly, and she needs another surgical operation. Margo would like a different surgeon with an outstanding professional reputation to perform the operation. The surgeon is not a member of the PPO network. Will Margo's plan pay for the surgery? Explain your answer.Explanation / Answer
Given:
Deductible = $ 1000
Co-insurance = 80/20
Out-of-pocket limit = $3000
Total Medical Expenses = $31000
Loss of pay= $4000
total expenses= $35000
$1000 covered by Margo
amount left= $34000
80% covered by insurer= $27,200
20% by Margo= $6800
Margo's out of pocket maximum limit is $3000
hence remaining 3800 $ should be covered by insurance company. Hence:
a. $3000+$1000 = $4000
b. Yes, she will pay a higher deductible and coinsurance in this case as the surgeon is not a member of the PPO network.