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

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Jamie Lee and Ross have a PPO, or preferred provider organization, plan.

In-Network Medical Care:

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

Out-of-Network Medical Care:

Jamie Lee and Ross have the choice of seeking medical care from the professional of their choice outside the PPO member list, but will incur a deductible of $500 per person/$1,000 per family, per year.

After the deductible is met, there is a coinsurance of 80 percent/20 percent. 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.

Page 317Questions


Using the information on the ACA and health planning from the “Personal Finance in Practice” box in this chapter, what are some of the strategies that Ross can use to better prepare financially for the arrival of the twins?


How could Jamie Lee and Ross prepare for the birth of the twins with their existing PPO plan?


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?


The doctor’s office has estimated the hospital expense for Jamie Lee and the babies’ delivery, without complications, to be approximately $18,000. Based on their health insurance policy, how much would Jamie Lee and Ross owe for this out-of-network hospital stay?


Surprise! The babies arrived five weeks early and Jamie Lee and Ross are the proud parents of triplets: two boys and a girl! Since they were preterm, they will need to spend a few extra days in the hospital for observation. How will Ross and Jamie Lee make provisions for adding the babies to their health insurance policy now that they have arrived?

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