Chapter 9 Insuring Your Health How Will This Affect Me? Having adequate health insurance is critically important to your financial plan. Health care costs have grown dramatically in recent years, and a major illness or accident could wipe you and your family out financially if you are uninsured. Yet health insurance policies are complicated to price and to compare. This chapter explains the importance of health insurance and the key determinants of its costs. The various types of public and private health insurance are described and a framework for decision making is provided. This includes discussions of how to analyze your health insurance needs, how to make sense of common policy features, and policy buying tips. While in political flux, the implications of the Patient Protection and Affordable Care Act of 2010 (ACA) in its current form on your decisions are considered. This chapter also discusses how to determine whether you need long-term care insurance or disability income insurance. After reading this chapter, you should understand how to insure your health most effectively and economically. Learning Objectives 9-1 Discuss why having adequate health insurance is important and identify the factors contributing to the growing cost of health insurance. The estimates of the increasing costs of health care should be noted. While it is true that two-thirds of health costs are incurred in the last three years of life, it is also true that inability to pay health costs is the number cause of individual bankruptcies. Health insurance is necessary to have a sound financial plan. Health risk avoidance, that is diet and exercise, should be emphasized. [OK, this is do as I say not as I do issue.] 9-2 Differentiate among the major types of health insurance plans and identify major private and public health insurance providers and their programs. Exhibit 9.2 gives a brief comparison of the major types of health insurance. The Affordable Care Act major provisions should be discussed. The Health Saving Accounts is discussed in Section 9-3b along with cafeteria plans. For young people who are generally healthy, the HSA is a good way to provide for health care throughout life—any unused funds roll over into the following year. 9-3 Analyze your own health insurance needs and explain how to shop for appropriate coverage. The information on Risk Avoidance is good and should be emphasized. The questions in Section 9-3c should be listed and discussed. While most will just take whatever group plan their employer offers, some will have to search out a plan on their own. 9-4 Explain the basic types of medical expenses covered by and the policy provisions of health insurance plans. The text does this and I would use the class time otherwise. The Major Medical Policy example in Section 9-4b will help students understand the computations involved with major medical. 9-5 Assess the need for and features of long-term-care insurance. The need for and the cost are the issues. Generally it covers nursing home care which is expensive, but the amount the insurance pays does not cover the cost. Also, note that the average nursing home stay is about 15 months, less than two years. The policy normally have a six month waiting period, so on average you get nine months of benefits. It is a costly decision, but for a risk adverse person it may be a good thing. 9-6 Discuss the features of disability income insurance and how to determine your need for it. Students probably identify disability insurance with the duck on the Aflac commercials. But most disability insurance is a group plan from their employer. The risk of needing disability insurance is small and the cost is small. The need can be great if you become disabled due to accident or illness. Key point is “cost is small”. Financial Facts or Fantasies? These may be used as “teasers” to get the students on the right page with you. Also, they may be used as quizzes after you covered the material or as “pre-test questions” to get their attention. Health care insurance coverage should be viewed as an essential component of your personal financial plans. Fact: Health care insurance not only helps you meet the costs of illness or injury, but it also protects your existing assets and financial plans. The difference between a health maintenance organization (HMO) and a preferred provider organization (PPO) is that the HMO offers a wider range of choices of physicians, hospitals, and so forth. Fantasy: One of the drawbacks of an HMO is that it is common to be treated at its central facility and by its own doctors. More options are, however, being offered. In a PPO, on the other hand, there are typically more opportunities to choose your health care providers from a network of designated physicians and hospitals. With health care insurance that covers the whole family, children may be included up to age 26 as long as they are full-time students. Fantasy: Under the Affordable Care Act a child may be covered in a family insurance plan so long as he or she is under 26 year of age. There is not a requirement that the child be a full-time student. Health reimbursement accounts (HRAs) and health savings accounts (HSAs) are both funded by employers to help their employees cover health-related costs – and any unused money is the employee’s to keep. Fantasy: While both accounts are consumer-directed plans, HRAs are funded solely by employers. In contrast, the money in HSAs is provided by employees, employers, or both to be spent on routine medical costs. If you change jobs, the HRA money remains with your employer. However, the money in an HSA belongs to the employee. Hospital insurance is the most comprehensive type of medical insurance you can buy. Fantasy: Major medical or comprehensive major medical provides the most complete coverage, whereas hospital insurance covers only the costs incurred while confined to a hospital. Disability insurance is helpful only if you make a lot of money – and then only if you are out of work for a long period of time (at least six months to a year). Fantasy: Disability income insurance replaces some or all of the weekly earnings lost in case you are physically unable to work. The coverage usually begins after a short waiting period and is just as valuable – perhaps more so – to the low-income family as it is to those with high incomes. Financial Facts or Fantasies? These may be used as a quiz or as a pre-test to get the students interested. 1. True False Health care insurance coverage should be viewed as an essential component of your personal financial plans. 2. True False The difference between a health maintenance organization (HMO) and a preferred provider organization (PPO) is that the HMO offers a wider range of choices of physicians, hospitals, and so forth. 3. True False With health care insurance that covers the whole family, children may be included up to age 26 as long as they are full-time students. 4. True False Health reimbursement accounts (HRAs) and health savings accounts (HSAs) are both funded by employers to help their employees cover health-related costs – and any unused money is the employee’s to keep. 5. True False Hospital insurance is the most comprehensive type of medical insurance you can buy. 6. True False Disability insurance is helpful only if you make a lot of money – and then only if you are out of work for a long period of time (at least six months to a year). Answers: 1. True 2. False 3. False 4. False 5. False 6. False YOU CAN DO IT NOW The “You Can Do It Now” cases may be assigned to the students as short cases or problems. They will help make the topic more real or relevant to the students. In most cases, it will only take about ten minutes to do, that is, until the student starts looking around at the web site. But they will learn by doing so. Compare Policies on an ACA Health Insurance Exchange It's worth taking the time to survey the policies and premiums available to you on an ACA health insurance marketplace. Just go to https://www.healthcare.gov/see-plans. All you have to do is put in your zip code and some basic information on yourself. If you're shopping, it provides useful information. And if you already have a plan through your job, it'll be interesting to see how it compares. It's easy and you can do it now. The following may be used as cases for the student to work, or for class discussion. Financial Impact of Personal Choices Read and think about the choices being made. Do you agree or not? Ask the students to discuss the choices being made. Henry Expands His Health Insurance Coverage Henry Morgan is 28 years old. He works for a company with a good health insurance plan. Indeed, Henry has heard it’s priced better than most plans and has consequently taken out the optional expanded dental and vision plans. While he doesn’t currently wear glasses or contact lenses, he does go for an annual eye exam and wants the extra vision plan in case he ends up needing corrective lens or has any eye problems. His plan has a $40 co-payment for an annual eye exam and pays $100 toward eye glass frames plus 20 percent of the rest of the cost. Contacts lenses have similar coverage. Henry pays just an additional $15 monthly premium for the vision plan. Henry feels more comfortable having expanded health insurance coverage. What do you think about Henry’s decision to purchase the vision insurance? While Henry feels better having expanded health insurance coverage in general and vision coverage in particular, it isn’t currently a cost effective decision. Henry makes a $40 co-payment for an annual eye exam, which is probably cheaper than the full cost of an eye exam. But he doesn’t wear glasses or contacts. His $15 monthly premium costs him $180 per year. It’s extremely unlikely that he saves anywhere near that much on the cost of his exam under the vision plan. And if Henry has a significant medical problem with his eyes, his major medical insurance plan should cover the costs well. It could make sense for him to have such expanded vision coverage in the future if corrective lenses are needed. So it appears that Josh’s comfort over having expanded vision coverage is costly. Insure Your Health! Health care costs have increased dramatically in recent years, and many insurance providers have reduced their coverage, leaving the individual to foot more of the bill. In this project, you’ll examine your health insurance needs and determine the coverage that’s appropriate for you. First, make a list of the possible health care needs you’re likely to have during the year. Be sure to include the potential accident risks to which you’re typically exposed in pursuit of your lifestyle activities. Then, if you currently have health insurance, make a list of the coverage it provides, including deductibles, co-insurance amounts, prescription coverage, policy limits and exclusions, and so forth. Is your coverage adequate in light of your needs? Are there ways you can reduce your costs? If you don’t currently have health insurance, research possible providers. Can you obtain insurance through your university, place of employment, or through an organization to which you belong? Do you qualify for insurance that may be provided by your state? Consider all of your feasible alternatives, the coverages that would be provided, and the cost of each. Financial Planning Exercises 1. Evaluating current health insurance. Assess your current health insurance situation. What does your policy cover? What is excluded? Are there any gaps that you think need to be filled? Are there any risks in your current lifestyle or situation that might make additional coverage necessary? If you were to purchase health insurance for yourself in the near future, what type of plan would you select, and why? What steps can you take to keep your health costs down? Worksheet 9.1 is designed to provide a framework for evaluating health insurance plans. Many of your students will be covered by their parents plans. The student may need to talk to their parents to determine what is covered. Most students will simply sign on to their employer’s health plan, so it will be hard for them to identify the plan they would purchase for themselves. Exercise 2 gives them the opportunity to search for a plan. To keep health cost down takes work. Diet and Exercise will do much to control health care costs. Otherwise, select a career that allows you to work in a hospital and get employee discounts. 2. Comparing health insurance policies. Use Worksheet 9.1. Lexi Thomas, a recent college graduate, has decided to accept a job offer from a nonprofit organization. She’ll earn $44,000 a year but will receive no employee health benefits. Lexi estimates that her monthly living expenses will be about $2,000 a month, including rent, food, transportation, and clothing. She has no health problems and expects to remain in good health in the near future. Using the Internet or other resources, gather information about three health insurance policies that Lexi could purchase on her own. Include at least one HMO. Use Worksheet 9.1 to compare the policies’ features. Should Lexi buy health insurance? Why or why not? Assuming that she does decide to purchase health insurance, which of the three policies would you recommend, and why? For 2018, Lexi will have a standard deduction of $12,000. Thus, her taxable income will be $44,000 – 12,000 = $32,000 and her taxes will be $952.50 + 12% * (32,000 – 9,525) = $3,649.50 In addition, she will probably have a state income tax of about 5% or $1,600. Thus, Lexi will have a maximum of $44,000 – 24,000 (living costs) – 3,649.5 (federal tax) – 1,600 (state tax) – 3,366 (FICA taxes) = $11,384.50 to pay for health insurance. Bottom line, she can only afford a high deductible policy [if that] that will provide protection for catastrophic medical event. The students will most likely not find a policy that she can afford. Worksheet 9.1 lists most services that could be required. Such detailed information may be difficult to find. I suggest that you direct them to find an HMO, an indemnity plan, and a high-deductible plan. You may suggest that they check the Affordable Care Act website for plans. Then discuss Lexi’s ability to purchase one of the insurance plans. You could note that Medicare is about $150 per month or $1,800 per year which she could afford if it was available to her as some politicians have proposed. 3. Choosing a health insurance plan. Harriet and Jake Sanders have two children, a six-year old and a five-months old. Their younger child, Alex was born with a congenital heart defect that will require several major surgeries in the next few years to correct fully. Jake is employed as a salesperson for a major pharmaceutical firm, and Harriet is a stay-at-home mother. Jake’s employer offers employees a choice between two health benefit plans: • An indemnity plan that allows the Sanders to choose health services from a wide range of doctors and hospitals. The plan pays 80 percent of all medical costs, and the Sanders are responsible for the other 20 percent. There’s a deductible of $500 per person. Jake’s employer will pay 100 percent of the cost of this plan for Jake, but the Sanderses will be responsible for paying $380 a month to cover Harriet and the children under this plan. • A group HMO. If the Sanders choose this plan, the company still pays 100 percent of the plan’s cost for Jake, but insurance for Harriet and the children will cost $295 a month. They’ll also have to make a $20 co-payment for any doctor’s office visits and prescription drugs. They will be restricted to using the HMO’s doctors and hospital for medical services. Which plan would you recommend that the Sanders choose? Why? What other health coverage options should they consider? The Sanders have a specific concern—their son’s heart problems. The choice of health plans will be determined by which plan has the doctors and hospital that they need for Alex’s surgery and recovery. If the HMO has the doctors and hospital that they need, then that is the better plan for the family. In some areas, the major hospital in the area will be the HMO hospital, but not all areas. The family needs to investigate the doctors and hospitals in their area to decide which health care provider they need. Then, select the health insurance that will cover services at the selected hospital. Most insurance plans have a stop-loss provision at which point 100% of costs are covered. The information does not indicate if the plan has a stop-loss provision. This needs to be investigated. However, the decision will still be based upon which plan will cover the providers that Alex needs. Other insurance available to the Sanders is most likely an individual policy. The cost will be greater and there will be no employer support, therefor that alternative is not acceptable. 4. Out-of-pocket indemnity plans costs. Samuel Nguyen was seriously injured in a skiing accident that broke both his legs and an arm. His medical expenses included five days of hospitalization at $900 a day, $6,200 in surgical fees, $4,300 in physician’s fees (including time in the hospital and eight follow-up office visits), $520 in prescription medications, and $2,100 for physical therapy treatments. All of these charges fall within customary and reasonable payment amounts. Samuel’s total expenses are [$900 * 5] + 6,200 + 4,300 + 520 + 2,100 = $17,620 a. If Samuel had an indemnity plan that pays 80 percent of his charges with a $500 deductible and a $5,000 stop-loss provision, how much would he have to pay out of pocket? Samuel’s out of pocket costs are $500 deductible plus 20% * [$17,620 – 500] = $3,924. b. What would Samuel’s out-of-pocket expenses be if he belonged to an HMO with a $20 co-pay for office visits? Samuel’s costs would be $20 per office visit, that is $20 * 8 = $160. c. Monthly premiums are $155 for the indemnity plan and $250 for the HMO. If he had no other medical expenses this year, which plan would have provided more cost-effective coverage for Samuel? What other factors should be considered when deciding between the two plans? The HMO costs $95 per month more, a total of $1,140 additional. The benefits are $3,924 – 160 = $3,764 more than the indemnity plan. That is an overall saving of $2,624. The HMO is more cost effective in this case. Other factors relate to the availability of the needed services from the HMO. For broken legs and arm, assuming no complications, the HMO providers will be acceptable. If not, then Samuel will be willing to pay the extra cost. 5. Evaluating health care coverage. Edward Allen was a self-employed window washer earning approximately $700 per week. One day, while cleaning windows on the eighth floor of the Second National Bank Building, he tripped and fell from the scaffolding to the pavement below. He sustained multiple severe injuries but miraculously survived the accident. He was immediately rushed to the local hospital for surgery. Edward remained there for 60 days of treatment, after which he was allowed to go home for further recuperation. During his hospital stay, he incurred the following expenses: surgeon, $7,500, physician, $2,000, hospital bill for room and board, $250 per day; nursing services, $1,200; anesthetics, $600; wheelchair rental, $100; ambulance, $150; and drugs, $350. Edward has a major medical policy that has a $3,000 deductible clause, an 80 percent co-insurance clause, internal limits of $180 per day on hospital room and board, and $1,500 as a maximum surgical fee. The policy provides no disability income benefits. a. Explain the policy provisions as they relate to deductibles, co-insurance, and internal limits. Deductibles: The initial amount not covered by an insurance policy and thus the insured’s responsibility; it’s usually determined on a calendar-year basis or on a per-illness or per-accident basis. In this case, the deductible is $3,000, so no benefits would be paid until insured has paid $3,000, Co-insurance: A provision in many health insurance policies stipulating that the insurer will pay some portion— say, 80 or 90 percent—of the amount of the covered loss in excess of the deductible. In this case, the co-insurance is 80% paid by insurance; so 20% paid by Edward. Internal limits: A feature commonly found in health insurance policies that limits the amounts that will be paid for certain specified expenses, even if the claim does not exceed overall policy limits. In this case, the insurance will only pay the first $180 per day for daily hospital charge. Edward will have to pay the additional $70 per day, for a total of $250 per day. Also, the maximum surgical fee that will be paid by the insurance is $1,500. The balance of $6,000 will have to be paid by Edward. The internal limits apply before the deductible is computed. This means that the additional amount over the internal limit paid by Edward does not count as part of the deductible. b. How much should Edward recover from the insurance company? How much must he pay out of his own pocket?
Medical Charge Paid by Edward Paid by Insurance
Surgeon fee of $7,500 $6,000, not part of deductible $1,500
Physician fee of $2,000 $2,000
Hospital bill, room and board, $250/day for 60 days, $15,000 $4,200, not part of deductible $10,800
Nursing Services $1,200 $1,200
anesthetics, $600 $ 600
wheelchair rental, $100 $ 100
ambulance, $150 $ 150
drugs, $350. $ 350
Total before deductible and co-pay $16,700
Deductible paid by Edward $3,000 -$3,000 = $13,700
Balance subject to co-pay of 80/20 20% * $13,700 = $2,740 80% * $13,700 = $10,960
Total $15,940 $10,960
c. Would any other policies have offered Edward additional protection? What about his inability to work while recovering from his injury? Disability insurance [like from the duck] would replace some of Edward’s lost income. This would be helpful in paying his part of the hospital bill. Since Edward is self-employed, workman’s compensation will not apply. d. Based on the information presented, how would you assess Edward’s health care insurance coverage? Explain. Edward’s income is $700 per week or about $3,000 per month. He may not be able to afford any better policy. If he could get a policy without the internal limits [in this case they cost him $10,200] he would be much better off. His gross income is about $36,000 and he has some expenses against that income. He may qualify for Medicaid in his state which will cover some of his expenses. 6. Pros and cons of long-term care insurance. Discuss the pros and cons of long-term-care insurance. Does it make sense for anyone in your family right now? Why or why not? What factors might change this assessment in the future? Pros of long-term care insurance include: protection of assets should a covered family member need lengthy nursing home care [an unlikely event, average length of stay is under 3 years for assisted living and under 2 years for nursing home) and the security of arranging in advance for coverage for nursing home care. The cost of long-term care [nursing home care] averages about $100,000 per year. The disadvantages are: 1) the high cost of this coverage; 2) by the time a person needs this coverage, inflation and rising health care costs may have rendered the benefits inadequate; and 3) if the covered person never needs these services, the premiums paid may be lost. Student assessment of their family's needs will differ, but they should consider if there is a history of debilitating disease in their family, if a family member currently has a health problem, who would be available to care for their family members, and if they can afford the premiums. 7. Calculating need for disability income insurance. Use Worksheet 9.2. Lorenzo Ricci, a 35-year-old computer programmer, earns $96,000 a year. His monthly take-home pay is $4,800. His wife, Siena, works part-time at their children’s elementary school but receives no benefits. Under state law, Lorenzo’s employer contributes to a workers’ compensation insurance fund that would provide $2,250 per month for six months if he were disabled and unable to work. a. Use Worksheet 9.2 to calculate Lorenzo’s disability insurance needs, assuming that he won’t qualify for Medicare under his Social Security benefits.
DISABILITY BENEFIT NEEDS
Name(s): Lorenzo Ricci
1. Estimate current monthly take-home pay $ 4,800
2. Estimate existing monthly disability benefits:
a. Social security benefits $________
b. Other government benefits ________
c. Company benefits ________
d. Group disability policy benefits 2,250
3. Total existing monthly disability benefits (2a + 2b + 2c + 2d) $ 2,250
4. Estimated monthly disability benefits needed ([1] – [3]) $ 2,550
b. Based on your answer in part a, what would you advise Lorenzo about his need for additional disability income insurance? Discuss the type and size of disability income insurance coverage he should consider, including possible provisions he might want to include. What other factors should he take into account if he decides to purchase a policy? Lorenzo needs to supplement his employer's disability insurance with an individual policy. The minimum he currently needs is $2,550 per month, and he will need $4,800 per month once his employer's plan coverage ends. He should decide how long his own assets would cover immediate needs so that he can choose a policy with a longer waiting period. The cost would be lessened if he purchases one with a 6-month waiting period which would kick in when his employer’s plan is exhausted. A non-cancellable policy is preferable because the premiums will not go up, but a guaranteed renewable policy would be more affordable. Other factors to assess include the length of the waiting period, the age at which benefits expire, and the availability of residual benefits if he is able to work part-time. Also, social security may be available if his disability extends for more than a year. 8. Calculating your need for disability income insurance. Use Worksheet 9.2. Do you need disability income insurance? Calculate your need using Worksheet 9.2. Discuss how you’d go about purchasing this coverage. Typically disability insurance is not very expensive, thus it is affordable. Group rates are normally lower and additional coverage may be available through the group policy. Such may be funded with a flexible benefit plan. Disability insurance is to replace lost income. If you are full-time student with no income, you do not need disability income insurance. Test Yourself 9-1 Why should health insurance planning be included in your personal financial plan? A study done at Harvard University indicates that medical expenses are the biggest cause of bankruptcy, representing 62% of all personal bankruptcies. Health costs are increasing yearly; the average health insurance premium increased by about 90% in 2014. Health insurance is necessary to protect your family wealth.
9-2 What factors have contributed to today’s high costs of health care and health insurance? It is commonly stated that the demand for health services is a function of supply. If the service is provided, it will be used and cost is not a limiting factor. In addition to the demand for health services driving the cost up, new technologies are being applied to health problems and the market pays whatever is asked. Third party payers are common and each third party is adding reporting and oversight costs to the cost of health. Most of health services are provided by corporate health organizations either for profit or not for profit. The extra overhead is not being covered by the efficiencies of size and is adding to the cost of health care. 9-3 What are the two main sources of health insurance coverage in the United States? Health insurance coverage is available from two main sources: private and government-sponsored programs. 9-4 What is group health insurance? Differentiate between group and individual health insurance. Group health insurance refers to health insurance contracts written between a group (such as an employer, union, credit union, or other organization) and the health care provider: a private insurance company, Blue Cross/Blue Shield plan, or a managed care organization. With group policies the under writer uses the statistics of the group to set the premium. Typically, a group will include some with very few health issues as well as some with many health issues. The sharing of the cost reduces the premium costs. With an individual health insurance policy the individual policy must covers all of the costs of health care, thus the premium is higher than group coverage. 9-5 Describe the features of traditional indemnity (fee-for-service) plans and explain the differences between them and managed care plans. Most private health insurance plans fall into one of two categories: traditional indemnity (fee-for-service) plans and managed care plans, which include health maintenance organizations (HMOs), preferred provider organizations (PPOs), and similar plans. Both types of plans provide financial aid for the cost of medical care arising from illness or accidents, but they do so in somewhat different ways. Exhibit 9.2 compares some features of the three most common types of health plans. The indemnity (fee-for-service) plans pays 80% of the usual, customary, and reasonable charges. The patient selects the medical provider who has no relation to the insurance company. In a managed care plan, subscribers/users contract with and make monthly payments directly to the organization that provides the health care service. An insurance company may not even be involved, although today most major health insurance companies offer both indemnity and managed care plans. Once you select the managed care organization, that organization selects the specific doctors or other providers of care. 9-6 Briefly explain how an HMO works. Compare and contrast group HMOs, IPAs, and PPOs. A health maintenance organization (HMO) is an organization of hospitals, physicians, and other health care providers who have joined to provide comprehensive health care services to its members. As an HMO member, you pay a monthly fee that varies according to the number of people in your family. An individual practice association (IPA) is the most popular type of HMO. IPA members receive medical care from individual physicians practicing from their own offices and from community hospitals that are affiliated with the IPA. As a member of an IPA, you have some choice of which doctors and hospitals to use. A preferred provider organization (PPO) is a managed care plan that has the characteristics of both an IPA and an indemnity plan. An insurance company or provider group contracts with a network of physicians and hospitals that agree to accept a negotiated fee for medical services provided to the PPO customers Unlike the HMO, however, a PPO also provides insurance coverage for medical services not provided by the PPO network, so you can choose to go to other doctors or hospitals. However, you will pay a higher price for medical services not provided by network doctors and hospitals. 9-7 Discuss the basics of the Blue Cross/Blue Shield plans. Blue Cross/Blue Shield plans historically were not insurance policies, but rather are prepaid hospital and medical expense plans. In recent years the Blues have incorporated as for profits organizations and work like an insurance company. Most offer both PPOs and HMOs as well as fee-for-service policies. 9-8 Who is eligible for Medicare and Medicaid benefits? What do those benefits encompass? Medicare is a federally funded and operated plan that provides health insurance to all who are 65 and older or receiving disability from Social Security. The doctors and other providers agree to accept the UCR fees and the patient will pay nothing for many services or 20% for some. Medicaid is a state program where eligibility various from state to state. The federal government pays most of the costs to the state. The Medicaid program is jointly funded by the federal government and states. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP). FMAP varies by state based on criteria such as per capita income. The regular average state FMAP is 57%, but ranges from 50% in wealthier states up to 75% in states with lower per capita incomes. 9-9 What is the objective of workers’ compensation insurance? Explain its benefits for employees who are injured on the job or become ill through work-related causes. Workers’ compensation insurance is designed to compensate workers who are injured on the job or become ill through work-related causes. Although mandated by the federal government, each state is responsible for setting workers’ compensation legislation and regulating its own program. Typical workers’ compensation benefits include medical and rehabilitation expenses, disability income, and scheduled lump-sum amounts for death and certain injuries, such as dismemberment. Employers bear nearly the entire cost of workers’ compensation insurance in most states. 9-10 What are the key provisions of the ACA? How is it likely to affect your health care insurance? The ACA has two key goals: Reduce the number of uninsured citizens in the country. All citizens not covered by Medicare or Medicaid are required to purchase insurance. Low income citizens may qualify for a tax credit to help pay for the insurance. Reduce the increases in health care costs by providing a “state based” health insurance exchange in each state. If the state elects not to operate a state exchange, its citizens may use the federal exchange. The impact on health care insurance is large. Insurance policies must provide a list of essential health benefits required by the ACA. The amount spent on administration and marketing of the insurance is restricted by the ACA. The insurance policies listed on the exchanges must offer levels of coverage from 60% to 90% of costs. 9-11 Explain four methods for controlling the risks associated with health care expenses. Recall from Chapter 8 that you can deal with risk in four ways: risk avoidance, loss prevention and control, risk assumption, and insurance. Risk avoidance: Look for ways to avoid exposure to health care loss before it occurs. For example, people who don’t take illegal drugs never have to worry about disability from overdose, people who refuse to ride on motorcycles avoid the risk of injury from this relatively dangerous means of transportation, and people who don’t smoke in bed are a lot less likely to doze off and start a fire in their house. Loss prevention and control: People who accept responsibility for their own well-being and live healthier lifestyles can prevent illness and reduce high medical costs. Smoking, alcohol and drug dependency, improper diet, inadequate sleep, and lack of regular exercise contribute to more than 60 percent of all diagnosed illnesses. Risk assumption: Consider the risks that you’re willing to retain as you deal with health insurance decisions. Some risks pose relatively small loss potential; you can budget for them rather than insure against them. Purchasing insurance is the last of the four. 9-12 Explain what factors should be considered in evaluating available employer-sponsored health insurance plans. Group plans are less expensive than individual plans. So the factors to examine are the alternatives that are offered. For example, a single person would not opt for family coverage. Vision and hearing options may not apply at this time and may be added at a later date. Many employers will offer a flexible benefit plan, referred to as a cafeteria plan by the enabling tax code. Under this plan, employees may request employers to withhold pretax funds that may be used to provide various benefits, including additional health coverage. Some employers will offer a Health Savings Account where the employer and employee may contribute pretax income to the plan. The funds may be used for health services in the current or later years. If by age 65 the funds have not been used, they may be added to retirement accounts although at that point they will be taxable when withdrawn. Another possible benefit is insurance for retirees. The employer may continue to pay some portion of insurance costs for their retired employees. 9-13 Discuss possible sources of health insurance available to supplement employer sponsored health insurance plans. Additional insurance is normally available from the group insurance provider, although the employee will have to pay the cost. This insurance may be funded with a flexible benefit account. The ACA does limit the amount of insurance a purchase may purchase. So called “Cadillac plans where the plan covers 100% of all costs are not allowed. 9-14 Answer the key questions posed to help you choose a plan, based on your current situation. What type of plan do you think will best suit your needs? The financial road sign, “Choosing a Health Insurance Plan” gives a list of questions to answer in selecting a plan. They are: Ask the following questions when choosing among health care insurance plans: • Can I choose to use any doctor, hospital, clinic, or pharmacy? • What coverage, if any, is provided for seeing specialists like eye doctors and dentists? • Does the plan cover special conditions or treatments like psychiatric care, pregnancy, and physical therapy? • Does the plan cover home care or nursing home care? • What kind of limitations are there on the coverage of prescribed medications? • What are the deductible and any co-payment amounts? • What is the maximum that I would have to pay out of health care expenses, either in a calendar year or during my lifetime? • How are billing or service disputes handled under the plan? Students may be willing to discuss possible answers to these questions in a classroom discussion. 9-15 Explain the differences between hospitalization insurance and surgical expense insurance. Hospitalization policies usually pay for a portion of: (1) the hospital’s daily semiprivate room rate, which typically includes meals, nursing care, and other routine services; and (2) the cost of ancillary services, such as laboratory tests, imaging, and medications you receive while hospitalized. Surgical expense coverage is provided as part of a hospitalization insurance policy or as a rider to such a policy. Most plans reimburse you for reasonable and customary surgical expenses based on a survey of surgical costs during the previous year. They may also cover anesthesia, nonemergency treatment using imaging, and a limited allowance for diagnostic tests. 9-16 What are the features of a major medical plan? Compare major medical to comprehensive major medical insurance. Major medical coverage is designed to finance medical costs of a more catastrophic nature and provides benefits for nearly all types of medical expenses resulting from either illnesses or accidents. The amounts that can be collected under this coverage are relatively large. Major medical coverage is typically written with provisions to limit payments, including deductibles, participation or coinsurance, and internal limits. Most policies now cap the insured's out-of-pocket payment through deductibles and coinsurance; after a certain dollar amount is paid by the insured, the company pays 100% of covered costs. Someone who must purchase insurance as an individual on a limited budget needs this protection the most. A comprehensive major medical insurance plan combines the basic hospital, surgical, and physician’s expense coverages with major medical protection to form a single policy and is usually the most desirable type of coverage to have. Usually the deductible is low, often $100 to $500. There may be no coinsurance feature. Comprehensive major medical is frequently written as a group policy, although individual policies are available. 9-17 Describe these policy provisions commonly found in medical expense plans: (a) deductibles, (b) co-insurance, and (c) coordination of benefits. A participation, or co-insurance, clause stipulates that the company will pay some portion—say, 80 percent or 90 percent—of the amount of the covered loss in excess of the deductible rather than the entire amount. Co-insurance helps reduce the possibility that policyholders will fake illness and discourages them from incurring unnecessary medical expenses. A coordination of benefits provision clause prevents you from collecting more than 100 percent of covered charges by collecting benefits from more than one policy. 9-18 What are the key provisions of COBRA? How do they relate to continuation of group coverage when an employee voluntarily or involuntarily leaves the insured group? When employees voluntarily or involuntarily (except in the case of gross misconduct) leave their jobs and therefore give up membership in the insurance group, they can lose their health insurance. In 1986, Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA) to allow employees to elect to continue coverage for themselves and eligible family members through the group for up to 18 months. Exercising the COBRA conversion involves timely payment of premiums by the former employee (up to 102% of the company cost) to the former employer. Retirees and their families are also eligible. Most states provide for conversion of the group coverage to an individual policy without evidence of insurability. 9-19 Explain the cost containment provisions commonly found in medical expense plans. How might the provision for second surgical opinions help an insurer contain its costs? Typical cost containment provisions include the following: Pre-admission certification: Insurance company must approve scheduled hospitalization and an estimated length of stay. Continued stay review: Insurer must approve extensions of hospital stay beyond the number of days set in pre-admission certification. Second surgical opinion: Many group policies require second opinions on specific nonemergency procedures to confirm the surgical need and, in their absence, may reduce the surgical benefits paid. Waiver of coinsurance: Provides waiver of co-payment and/or deductible (pays 100%) for certain cost-saving procedures, such as outpatient surgery and use of generic pharmaceuticals. Limitation of Insurer's Responsibility: Many policies limit the amount of costs the insurer must pay to those considered "reasonable and usual." This provision sometimes limits the type and place of medical care for which the insurer will pay. Requiring a second surgical opinion reduces the number of unnecessary, nonelective, and/or elective surgeries, thereby holding down the insurer's costs. Many conditions can now be treated without surgery or with surgery that is not so invasive and requires less hospital and recovery time for the patient. This provision obviously benefits patients as well in that they are not subjected to the trauma and recovery from unnecessary surgery as well as possibly wages lost due to not being able to work. 9-20 Why should a consumer consider purchasing a long-term care insurance policy? Most regular health care policies do not cover the cost of long-term care. As more of the population lives longer, there is a greater likelihood that many people will at some point in their lives be unable to care for themselves for an extended time period. Long-term care insurance covers the cost of medical, personal, and social services provided at home, in a community program such as an adult day-care center, or in a nursing home for those who require long-term care as a result of a catastrophic illness such as Alzheimer's disease, heart disease, and stroke. This care can be very expensive, and it is therefore important to consider adding long-term care coverage when developing financial plans. 9-21 Describe the differences among long-term-care policies regarding (a) type of care, (b) eligibility requirements, and (c) services covered. List and discuss some other important policy provisions. a. Type of care: Policies will cover care in either a nursing home or in the home of the insured, or both. Obviously, a better policy will cover both situations. b. Eligibility requirements: These are used to determine whether a person qualifies for payment and use "gatekeeper provisions" that may vary considerably. Some policies pay if a physician orders long-term care; others base their determination on the number of activities of daily living (ADLs) the insured cannot perform. c. Services covered: Policies may differ in the levels of care that they will cover (skilled, intermediate, or custodial care). The broader the coverage, the better, because even custodial care at a nursing home can be very expensive over a long period of time. Other long-term care policy provisions include: Daily benefits—sets a daily maximum for reimbursement. Benefit duration—how long the benefits will be paid; ranges from one year to the insured's lifetime. However, most common policy limits coverage to three years. Waiting period—period after eligibility begins during which no benefit payments are made; the longer the waiting period, the lower the premium. Renewability—guaranteed renewability assures continued coverage as long as premiums are paid; an optional renewability provision means that the insurer can terminate coverage and should obviously be avoided. Preexisting conditions—excludes coverage for conditions that exist when the policy is issued, usually for 6 to 12 months. Inflation protection—provides for increased coverage to keep up with inflation; an additional premium is charged for this rider. Premium levels—the age of the individual when the policy is initiated determines the premium; premiums go up dramatically with age. 9-22 Discuss some of the questions one should ask before buying long-term-care insurance. What guidelines can be used to choose the right policy? The Financial Planning Tips covers buying long-term care insurance. The major points are: Buy the right amount and the right kind of coverage. Buy at the right time. Be aware of the “restoration of benefits” rider, as well as the rest of the fine print. Take inflation into account. Additional questions to ask are: Do you have many assets to preserve for your dependents? Can you afford the premiums? Is there a family history of disabling disease? Are you male or female? Do you have family who can care for you? 9-23 What is disability income insurance? Explain the waiting-period provisions found in such policies. Disability income insurance provides families with weekly or monthly payments to replace income when the insured is unable to work because of a covered illness, injury, or disease. Social Security offers disability income benefits, but you must be unable to do any job whatsoever to receive benefits. Benefits are payable only if your disability is expected to last at least one year (or to be fatal), and they don’t begin until you’ve been disabled for at least five months. 9-24 Describe both the liberal and strict definitions used to establish whether an insured is disabled. Disability policies vary in the standards you must meet to receive benefits. Some pay benefits if you’re unable to perform the duties of your customary occupation—the own occupation (or “Own Occ”) definition—whereas others pay only if you can engage in no gainful employment at all—the any occupation (or “Any Occ”) definition. Under the “Own Occ” definition, a professor who lost his voice—yet could still be paid to write or do research—would receive full benefits because he couldn’t lecture, a primary function of his occupation. With a residual benefit option, you would be paid partial benefits if you can only work part-time or at a lower salary. The “Any Occ” definition is considerably less expensive because it gives the insurer more leeway in determining whether the insured should receive benefits. Individual disability policies may contain a presumptive disability clause that supersedes the previously discussed definition of disability when certain types of losses occur. Loss of both hands, sight in both eyes, and hearing in both ears are examples where the insured may be presumed totally disabled and may receive full benefits even though he or she still can be employed in some capacity. 9-25 Why is it important to consider benefit duration when shopping for disability income coverage? The benefit duration determines whether the disability coverage will be for a specific time period or for a lifetime. The choice depends on whether or not the insured has good pension benefits that start at age 65 so that disability coverage would no longer be necessary. Also, the average length of stay in a nursing home is about two years. Critical Thinking Cases 9.1 Evaluating Walter’s Health Care Coverage Walter Burton was a self-employed window washer earning approximately $700 per week. One day, while cleaning windows on the eighth floor of the Commercial Bank Building, he tripped and fell from the scaffolding to the pavement below. He sustained severe multiple injuries but miraculously survived the accident. He was immediately rushed to the local hospital for surgery. He remained there for 60 days of treatment, after which he was allowed to go home for further recuperation. During his hospital stay, he incurred the following expenses: surgeon, $2,500; physician, $1,000; hospital bill for room and board, $250 per day; nursing services, $1,200; anesthetics, $600; wheelchair rental, $100; ambulance, $150; and drugs, $350. Walter has a major medical policy that has a $3,000 deductible clause, an 80 percent co-insurance clause, internal limits of $180 per day on hospital room and board, and $1,500 as a maximum surgical fee. The policy provides no disability income benefits. Critical Thinking Questions 1. Explain the policy provisions as they relate to deductibles, co-insurance, and internal limits. $3,000 deductible: He must incur $3,000 in costs before the policy will pay anything, 80% co-insurance: After the deductible is met, the policy will pay 80% of the costs. He is responsible for the other 20% until he the stop-loss amount is reached. Internal limits: This policy has additional limits on specific charges. Thus, of the $250 per day hospital charge, the policy will only pay $180 – Walter is responsible of the other $70 per day. The $70 will not count toward his $3,000 deductible, but may be considered in determining the stop-loss amount. The other limit is surgical fee. Walter incurred $2,500 surgeon fee but policy will only cover $1,500. The additional $1,000 must be paid by Walter. Again, the additional fee does not count toward the deductible, but may count toward the stop-loss amount. 2. How much should Walter recover from the insurance company? How much must he pay out of his own pocket?
Expense Item Charge Paid by Insurance Paid by Walter
Surgeon $2,500 1,500 1,000
Physician 1,000 1,000
Hospital room, board (Charged $250 x 60 days; limit $180 x 60 days) 15,000 10,800 4,200
Nursing 1,200 1,200
Anesthetics 600 600
Wheelchair 100 100
Ambulance 150 150
Drugs 350 350
Total $20,900 $15,700
Deductible 3,000 3,000
After deductible $12,700
Payment is 80%/20% 10,160 2,540
$10,740
3. Would any other policies have offered Walter additional protection? What about his inability to work while recovering from his injury? He would qualify for disability benefits if he had disability insurance. With his income level, he would qualify for Medicaid in some states, but not all. If he qualifies for Medicaid, he could use his insurance dollars to purchase disability insurance that would help covers the expenses not otherwise covered. Also, since he was hurt on the job, workman’s compensation may cover the injury related expenses. 4. Based on the information presented, how would you assess Walter’s health care insurance coverage? Explain. Most likely, he cannot afford any additional insurance. It does cover about half of the expenses. Under ACA, the lowest acceptable coverage is 60%, which is more than the insurance in the case. 9.2 Luis and Dora Barillas Evaluate Their Disability Income Needs Luis Barillas and his wife, Dora, have been married for two years and have a 1-year-old son. They live in Charlotte, North Carolina, where Luis works for Advanced Marketing Analytics. He earns $3,200 per month, of which he takes home $2,300. Luis and his family are entitled to receive the benefits provided by the company’s group health insurance policy. In addition to major medical coverage, the policy provides a monthly disability income benefit amounting to 20 percent of the employee’s average monthly take-home pay for the most recent 12 months prior to incurring the disability. (Note: Luis’s average monthly take-home pay for the most recent year is equal to his current monthly take-home pay.) In case of complete disability, Luis would also be eligible for Social Security payments of $700 per month. Dora is also employed. She earns $700 per month after taxes by working part-time at a nearby grocery store. As a part-time employee, the store gives her no benefits. Should Luis become disabled, Dora would continue to work at her part-time job. If she became disabled, Social Security would provide monthly income of $400. Luis and Dora spend 90 percent of their combined take-home pay to meet their bills and provide for a variety of necessary items. They use the remaining 10 percent to fulfill their entertainment and savings goals. Critical Thinking Questions 1. How much, if any, additional disability income insurance does Luis require to ensure adequate protection against his becoming completely disabled? Use Worksheet 9.2 to assess his needs.
DISABILITY BENEFIT NEEDS
Name(s): Luis Barillas
1. Estimate current monthly take-home pay $ 2,300
2. Estimate existing monthly disability benefits:
a. Social security benefits $____700_
b. Other government benefits ________
c. Company benefits _____460_
d. Group disability policy benefits
3. Total existing monthly disability benefits (2a + 2b + 2c + 2d) $ 1,160
4. Estimated monthly disability benefits needed ([1] – [3]) $ 1,140
Luis would need additional disability insurance to completely replace his take-home pay. Without the additional disability insurance, his family would be at risk of losing their savings and would have a substantially different life style. 2. Does Dora need any disability income coverage? Explain. If Dora became disable, the only disability income would be from Social Security of $400 per month. Her current part-time income is $700 per month, thus the family income would be $300 a month less. Their estimated expenses are 90% of their total take home pay of (2,300 + 700) or $2,100 per month. With Dora’s Social Security, they would have $2,300 + $400, total of $2,700. Thus, they would be able to cover their current living expenses. Dora does not need to purchase disability insurance. 3. What specific recommendations regarding disability income insurance would you give Luis and Dora to provide adequate protection for themselves and their child? Luis needs additional disability insurance. First he should check with his employer to see if he can purchase additional coverage through the group plan. If not, he should search for insurance companies that provide such coverage. The family needs to establish a saving plan to help provide for emergencies that may arise. Terms Found in the Chapter Below are the terms that are highlighted in the chapter. You could use this table to create matching questions for a quiz. Or you just find it useful to quickly get a definition for a term.
Blue Cross/Blue Shield plans Prepaid hospital and medical expense plans under which health care services are provided to plan participants by member hospitals and physicians.
Community rating approach to health insurance premium pricing Policyholders in a community (area) pay the same premium without regard to their personal health, age, gender, or other factors.
comprehensive major medical insurance A health insurance plan that combines into a single policy the coverage for basic hospitalization, surgical, and physician expenses along with major medical protection.
coordination of benefits provision A provision often included in health insurance policies to prevent the insured from collecting more than 100 percent of covered charges; it requires that benefit payments be coordinated if the insured is eligible for benefits under more than one policy.
deductible The initial amount not covered by an insurance policy and thus the insured’s responsibility; it’s usually determined on a calendar-year basis or on a per-illness or per-accident basis.
disability income insurance Insurance that provides families with weekly or monthly payments to replace income when the insured is unable to work because of a covered illness, injury, or disease.
exclusive provider organization (EPO) A managed care plan that is similar to a PPO but reimburses members only when affiliated providers are used.
flexible spending account (FSA) Employee pre-tax contributions to an account that must be spent on qualified medical (or dependent care) expenses.
group HMO An HMO that provides health care services from a central facility; most prevalent in larger cities.
group health insurance Health insurance consisting of contracts written between a group (employer, union, etc.) and the health care provider.
guaranteed renewability A policy provision ensuring continued insurance coverage for the insured’s lifetime, so long as the premiums continue to be paid.
Health Insurance Portability and Accountability Act (HIPAA) A federal law that protects people’s ability to obtain continued health insurance after they leave a job or retire, even if they have a serious health problem.
health maintenance organization (HMO) An organization of hospitals, physicians, and other health care providers that have joined to provide comprehensive health care services to its members, who pay a monthly fee.
health reimbursement account (HRA) An account into which employers place contributions that employees can use to pay for medical expenses. Usually combined with a high deductible health insurance policy.
health savings account (HSA) A tax-free savings account—funded by employees, employer, or both—to spend on routine medical costs. Usually combined with a high deductible policy to pay for catastrophic care.
indemnity (fee-for service) plan A health insurance plan in which the health care provider is separate from the insurer, who pays the provider or reimburses you for a specified percentage of expenses after a deductible amount has been met.
individual practice association (IPA) A form of HMO in which subscribers receive services from physicians practicing from their own offices and from community hospitals affiliated with the IPA.
internal limits A feature commonly found in health insurance policies that limits the amounts that will be paid for certain specified expenses, even if the claim does not exceed overall policy limits.
long-term care The delivery of medical and personal care, other than hospital care, to persons with chronic medical conditions resulting from either illness or frailty.
major medical plan An insurance plan designed to supplement the basic coverage of hospitalization, surgical, and physician expenses; used to finance more catastrophic medical costs.
managed care plan A health care plan in which subscribers/users contract with the provider organization, which uses a designated group of providers meeting specific selection standards to furnish health care services for a monthly fee.
Medicaid A state-run public assistance program that provides health insurance benefits only to those who are unable to pay for health care.
Medicare A health insurance plan administered by the federal government to help persons age 65 and over, and others receiving monthly Social Security disability benefits, to meet their health care costs.
Medicare Advantage plans Commonly called Plan C, these plans provide Medicare benefits to eligible people, but they differ in that they are administered by private providers rather than by the government. Common supplemental benefits include vision, hearing, dental, general checkups, and health and wellness programs.
optional renewability A contractual clause allowing the insured to continue insurance only at the insurer’s option.
participation (co-insurance) clause A provision in many health insurance policies stipulating that the insurer will pay some portion— say, 80 or 90 percent—of the amount of the covered loss in excess of the deductible
Patient Protection and Affordable Care Act and the Reconciliation Act of 2010 Health care reform legislation that requires all Americans to have or buy health insurance, requires insurers to cover the children of those they insure up to the age of 26, prohibits insurers from denying coverage or setting unrealistically high premiums for pre-existing medical conditions, establishes health care insurance exchanges, and requires small firms to provide health insurance coverage for its employees.
pre-existing condition clause A clause that used to be included in most individual health insurance policies permitting permanent or temporary exclusion of coverage for any physical or mental problems the insured had at the time the policy was purchased; under the ACA, insurers now are prohibited from denying coverage for preexisting conditions, making this clause moot.
prescription drug coverage A voluntary program under Medicare (commonly called Part D), insurance that covers both brand-name and generic prescription drugs at participating pharmacies. Participants pay a monthly fee and a yearly deductible and must also pay part of the cost of prescriptions, including a copayment or co-insurance.
point-of-service (POS) plan A hybrid form of HMO that allows members to go outside the HMO network for care and reimburses them at a specified percentage of the cost.
preferred provider organization (PPO) A health provider that combines the characteristics of the IPA form of HMO with an indemnity plan to provide comprehensive health care services to its subscribers within a network of physicians and hospitals.
supplementary medical insurance (SMI) A voluntary program under Medicare (commonly called Part B) that provides payments for services not covered under basic hospital insurance (Part A).
waiting (elimination) period The period after an insured meets the policy’s eligibility requirements, during which he or she must pay expenses out-of-pocket; when the waiting period expires, the insured begins to receive benefits.
workers’ compensation insurance Health insurance required by state and federal governments and paid nearly in full by employers in most states; it compensates workers for job-related illness or injury.
Insuring Your Health Chapter Outline Learning Objectives I. The Importance of Health Insurance Coverage II. Health Insurance Plans A. Private Health Insurance Plans 1. Traditional Indemnity (Fee-for-Service) Plans 2. Managed Care Plans a. Health Maintenance Organizations (HMO) b. Preferred Provider Organizations (PPO) c. Other Managed Care Plans 3. Blue Cross/Blue Shield Plans B. Government Health Insurance Plans 1. Medicare 2. Medicaid 3. Workers' Compensation Insurance C. Rationale for Health Care Reform 1. Affordable Health Care Act of 2010 III. Health Insurance Decisions A. Evaluate Your Health Care Cost Risk B. Determine Available Coverage and Resources C. Choose a Health Insurance Plan IV. Medical Expense Coverage and Policy Provisions A. Types of Medical Expense Coverage 1. Hospitalization 2. Surgical Expenses 3. Physician Expenses 4. Major Medical Insurance 5. Comprehensive Major Medical Insurance 6. Dental Services B. Policy Provisions of Medical Expense Plans 1. Terms of Payment a. Deductibles b. Participation (Co-insurance) c. Internal Limits d. Major Medical Policy: An Example e. Coordination of Benefits 2. Terms of Coverage a. Persons and Places Covered b. Cancellation c. Pre-existing Conditions d. Pregnancy and Abortion e. Mental Illness f. Rehabilitation Coverage g. Continuation of Group Coverage C. Cost Containment Provisions for Medical Expense Plans V. Long-Term Care Insurance A. Do You Need Long-Term Care Insurance? B. Long-Term Care Insurance Provisions and Costs C. How to Buy Long-Term Care Insurance VI. Disability Income Insurance A. Estimating Your Disability Insurance Needs B. Disability Income Insurance Provisions and Costs 1. Definition of Disability 2. Benefit Amount and Duration 3. Probationary Period 4. Waiting Period 5. Renewability 6. Other Provisions Solution Manual for Personal Finance Michael Joehnk , Randall Billingsley , Lawrence Gitman 9780357033609
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