Transcript Health Insurance

Objective 5.02
Health Insurance
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Insurance Vocabulary
Policy - contract between the insurer
and insured
 Premium – cost of insurance
 Insurer – company offering policy
 Insured – policyholder who buys a policy
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Insurance Vocabulary
Claim- when policy holder needs insurer
to pay for a financial loss
 Co-pays- the amount the policyholder
owes on a health insurance claim
 Deductible - amount paid by
policyholder before insurance pays
 Face amount - $ value of life insurance
policy to be paid
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Health Care Issues
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Make smart health care decisions!!
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Research different health care providers
Be honest on applications
Be certain you understand all exclusions and
conditions
Be aware of expiration dates, cancellation terms, and
renewal policies
Power of attorney: court document naming someone
who has permission to act on the person’s behalf in
case of illness or inability to perform their normal
duties
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Health Care Issues
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Make smart health care decisions!!
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Research different health care providers
Be honest on applications
Be certain you understand all exclusions and
conditions
Be aware of expiration dates, cancellation terms, and
renewal policies
Power of attorney: court document naming someone
who has permission to act on the person’s behalf in
case of illness or inability to perform their normal
duties
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Health Insurance Coverage
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Hospital or Hospitalization
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Covers for most or all of the charges during a stay
in the hospital.
Covers such charges as room, food, anesthesia, Xrays, laboratory tests, and medicines
The average cost of a one day hospital stay is
$5,000.
Over 30% of the US population between 18 and 24
is uninsured.
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Health Insurance Coverage
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Surgical Insurance
Covers all or part of the surgeon’s fees for
an operation.
 Usually bought in combination with hospital
insurance.
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Health Insurance Coverage
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Regular or Basic Medical insurance
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Covers fees for nonsurgical care given in
the doctor’s office, the patient’s home, or a
hospital.
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Health Insurance Coverage
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Major Medical / Mini Medical Ins.
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Covers cost of extended and specialized care out
of the hospital such as medicine and special
nursing care, X-rays & some psychiatric care
 Pays for extended and serious illnesses
 Pays for all or most of all kinds of health care
prescribed by a doctor
 Deductable – part you pay first
 Coinsurance – sharing of expenses
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Health Insurance Coverage
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May require patient to pay:
Annual deductible before insurer pays
anything
 A flat co-pay for doctor visits
 A %(10-30%) of the remaining balance due
 A maximum out of pocket expense each plan
year
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Health Insurance Coverage
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Comprehensive Medical Policy
Combines the features of hospital, surgical,
regular, and major medical insurance.
 Most common group health insurance policy
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Health Insurance Coverage
A
broad medical policy covering
Inpatient and outpatient hospital care
 Long term hospitalization
 Home nursing care
 Prescription drugs
 Physician visits
 Surgery
 Laboratory tests
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Health Insurance Providers
Health insurance may be obtained
through employer related groups.
Options include:
Group health insurance
 Managed care plans
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Health Maintenance Organizations (HMO)
Preferred Provider Organizations (PPO)
State Government Programs
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Health Insurance Providers
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Group Health Insurance
Most popular way to buy health insurance
 Companies pay part or all of the premium
for their employees
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Health Insurance Providers
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Managed Care Plans
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Health Maintenance Organization (HMO)
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Consists of a staffed medical clinic to serve members.
Objective-preventive care
Members are entitled to a wide range of prepaid health care
services, including hospitalization.
Primary Care Physician
In-Network Providers
Consists of a staffed medical clinic to serve members.
Members are entitled to a wide range of prepaid health care services,
including hospitalization.
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Managed Care Plans
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Preferred Provider Organization (PPO)
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Provides a group of physicians, a clinic, or a hospital that
contract with an insurance company.
Providers agree to charge a set fee for services.
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Members are encouraged but not required to use the PPO services. Greater
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flexibility
Out-Of-Network
Higher Out-Of-Pocket
May be “open access”
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Health Insurance Providers
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HMO POS
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An HMO POS combines the characteristics of an
Health Maintenance Organization and a Point of
Service Option program
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Patient required to choose a primary care physician
to monitor the patient's health. This physician must
be chosen from within the health care network, and
becomes their "point of service".
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Individual Healthcare Insurance
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Private or Individual Healthcare Plans
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You are self employed
Your employer does not offer a group plan
You are enrolled in a group plan, but it does not
cover spouses or dependents
You are enrolled in a health plan, but the premiums
are too high
You are enrolled in a health plan, but your benefits
needs have change
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Supplemental Health Coverage
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Cancer Insurance
A cancer insurance policy is usually
affordable and does not affect your existing
health insurance plan.
 It is either a supplemental policy or a stand
alone policy as an independent insurance
product.
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Supplemental Health Coverage
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Dental Insurance
Contains deductible and coinsurance to
reduce the cost of premiums.
 Covers examinations, X rays, cleaning and
filling.
 Covers dental injuries resulting from
accidents.
 Covers part of complicated dental work
such as crowns or bridges.
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Supplemental Health Coverage
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Long Term Care
An insurance product that covers long-term
care costs that go beyond a predetermined
period.
 Extends coverage beyond that covered by
existing healthcare insurance, Medicare, or
Medicaid.
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Supplemental Health Coverage
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Vision Care Insurance
Covers eye examinations, prescription
lenses, frames, and contact lenses.
 Some plans cover the cost of laser eye
surgery that eliminates the need for glasses.
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Supplemental Health Coverage
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Income Disability Insurance
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Protect the individual against risk of losing income
from regular occupation due to illness or injury
causing disability.
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Insured may buy a policy from a private company.
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Indemnifies for wages lost
 Proceeds (benefits paid) are not taxable
 Proceeds are 65% of normal wage
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Supplemental Health Coverage
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Private Disability Insurance:
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Dollar Amount of disability benefit requested
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Length of elimination period
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Risk involved in type of work
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Company
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Age
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Health
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Supplemental Health Coverage
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Private Disability Insurance:
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For private disability insurance, the
insured chooses:
Short term or long term policy
 Total or partial disability options
 Elimination period - number of weeks before
claim is payable
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Supplemental Health Coverage
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Private Disability Insurance
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Elimination period or waiting period is the number
of days or weeks that the insured waits before the
insurer pays disability claim
Form of risk retention
Comparable to a deductible
Cause and effect similar to a deductible:
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Longer elimination period=lower premium
Shorter elimination period=higher premium
Worksheet:
Health
Insurance
Search
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Disability Review
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Answer the following questions:
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T/F Employers can discriminate against
individuals with disabilities.
What is the difference in indirect and direct
discrimination
What is the purpose of Private Income
Disability Insurance?
From private disability insurance, what can the
insured choose?
What is the difference in a longer and shorter
elimination period?
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Government Insurance Coverage
Medicare: Provides health coverage for
most people over age 65 and some
disabled persons, provides medical and
hospital insurance
 Medicaid: Covers certain individuals who
need public assistance
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Government Insurance Coverage
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Medigap Insurance
Sometimes referred to as Medicare
Supplemental Insurance
 Designed to cover the "gap" between the
expenses reimbursed by Medicare and the
total amount charged.
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Patient Protection & Affordable Care
Act(PPACA) of 2010 – “ObamaCare”
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The Affordable Care Act is designed to increase the quality,
accessibility and affordability of health insurance.
Most people, who can afford to, must obtain health coverage by
2014 or pay a per month fee.
This law:
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Eliminates pre-existing conditions
Stops insurance companies from dropping you when you are sick
Restricts gender discrimination
Expands free preventative services and health benefits
Expands Medicaid and CHIP
Modifies Medicare by mandating that larger employers insure employees
Hopes to create a marketplace for subsidized insurance providing tens of
millions individuals, families and small businesses with free or low-cost
health insurance
Promises to decrease healthcare spending and the deficit.
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Patient Protection & Affordable Care
Act(PPACA) of 2010 – “ObamaCare”
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Rights and Protections
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Insurance Choices
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How does your health insurance policy affect your wallet? Find out how the law
helps you get the most value for your premium dollar.
65 or Older
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If you need insurance coverage or have been rejected due to a health condition
or disability, you may be eligible for coverage through one of these programs.
Insurance Costs
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If you have insurance, these consumer protections can help you get the most out
of your plan.
The health care law strengthens Medicare and provides access to preventive
services and prescription drug discounts for seniors.
Employers
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Tax credits and new programs are available to small businesses to help make
care more affordable for employers, employees, and early retirees
http://obamacarefacts.com/obamacare-explained.php
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State Government Insurance Coverage
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Worker’s compensation
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Provides medical and survivor benefits for
people injured, disabled, or killed on the job
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Government Insurance Coverage
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Disability Income Insurance
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Pays for loss of income due to extended illness or
accident
Social Security - Disability
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Know the Legal Issues
involved with Health Care
 Types of consent
 General consent: permission given for
tests and treatments, the moment the
patient enters the hospital
 Informed consent: procedure which
requires physicians to tell patients in
advance of any risks involved in forthcoming
treatment; must be in writing
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Health Insurance Review
Answer the following questions:
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Explain the difference between general and
informed consent.
What does basic health care cover?
What two ways can Major Medical Insurance
be purchased?
Name 4 cost factors for Health Insurance.
What is the difference in Medicare and
Medicaid?
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