Objective 5.02 Health Insurance

Insurance Vocabulary Policy - contract between the insurer and insured Premium – cost of insurance Insurer – company offering policy Insured – policyholder who buys a policy

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

Health Care Issues Make smart health care decisions!! 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

Health Care Issues Make smart health care decisions!! 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

Health Insurance Coverage Hospital or Hospitalization Covers for most or all of the charges during a stay in the hospital. Covers such charges as room, food, anesthesia, X-rays, 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.

Health Insurance Coverage Surgical Insurance Covers all or part of the surgeon’s fees for an operation. Usually bought in combination with hospital insurance.

Health Insurance Coverage Regular or Basic Medical insurance Covers fees for nonsurgical care given in the doctor’s office, the patient’s home, or a hospital.

Health Insurance Coverage Major Medical / Mini Medical Ins. 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

Health Insurance Coverage 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

Health Insurance Coverage Comprehensive Medical Policy Combines the features of hospital, surgical, regular, and major medical insurance. Most common group health insurance policy

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

Health Insurance Providers Health insurance may be obtained through employer related groups. Options include: Group health insurance Managed care plans Health Maintenance Organizations (HMO) Preferred Provider Organizations (PPO) State Government Programs

Health Insurance Providers Group Health Insurance Most popular way to buy health insurance Companies pay part or all of the premium for their employees

Health Insurance Providers Managed Care Plans Health Maintenance Organization (HMO) 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

Managed Care Plans Preferred Provider Organization (PPO) 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. Members are encouraged but not required to use the PPO services. Greater flexibility Out-Of-Network Higher Out-Of-Pocket May be “open access”

Health Insurance Providers HMO POS An HMO POS combines the characteristics of an Health Maintenance Organization and a Point of Service Option program 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".

Individual Healthcare Insurance Private or Individual Healthcare Plans 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

Supplemental Health Coverage 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.

Supplemental Health Coverage 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.

Supplemental Health Coverage 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.

Supplemental Health Coverage 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.

Supplemental Health Coverage Income Disability Insurance Protect the individual against risk of losing income from regular occupation due to illness or injury causing disability. Insured may buy a policy from a private company. Indemnifies for wages lost Proceeds (benefits paid) are not taxable Proceeds are 65% of normal wage

Supplemental Health Coverage Private Disability Insurance: Dollar Amount of disability benefit requested Length of elimination period Risk involved in type of work Company Age Health

Supplemental Health Coverage Private Disability Insurance: 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

Supplemental Health Coverage Private Disability Insurance 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: Longer elimination period=lower premium Shorter elimination period=higher premium Worksheet: Health Insurance Search

Disability Review Answer the following questions: 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?

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

Government Insurance Coverage 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.

Patient Protection & Affordable Care Act(PPACA) of 2010 – “ObamaCare” 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: 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.

Patient Protection & Affordable Care Act(PPACA) of 2010 – “ObamaCare” Rights and Protections If you have insurance, these consumer protections can help you get the most out of your plan. Insurance Choices 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 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 The health care law strengthens Medicare and provides access to preventive services and prescription drug discounts for seniors. Employers 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

State Government Insurance Coverage Worker’s compensation Provides medical and survivor benefits for people injured, disabled, or killed on the job

Government Insurance Coverage Disability Income Insurance Pays for loss of income due to extended illness or accident Social Security - Disability

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

Health Insurance Review Answer the following questions: 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?