Health Insurance Chapter 41

Objectives Today… Describe the five types of medical health insurance Explain managed health care and define the main type of managed care plans Discuss the reasons for disability income insurance List health insurance plans provided by the government. Objectives Today…

The insurance industry has created several kinds of health related insurance coverage Medical insurance dental insurance vision care insurance disability insurance

5 types of Medical Insurance Hospital Surgical Regular Medical Major Medical Comprehensive Medical Policy

Hospital Coverage includes: Charges for your room Anesthesia X-Rays Laboratory Tests Medication while in hospital

Surgical Coverage includes: Fees for operation Covered procedures listed & Exclusions listed in plan Most things are included but some vary from plan to plan. Sterilization. Things usually excluded include sterilization reversals, cosmetic, experimental, research lacking support of successful results.

Regular Medical Insurance Non-Surgical care Dr Office diagnostics & lab fees many combined with hospital coverage

Regular medical, hospital, and surgical coverage combined is referred to as Basic Health Coverage

Major Medical Insurance Protects against the high cost of serious illnesses or injuries Cancer | Coma | Special nursing care Health care prescribed by a doctor in an out of the hospital. X-Rays, psychiatric care, medicine and many other health care needs (wheel chairs.) Major Medical Insurance

Deductible Clause All major medical policies have a deductible clause. Maximum benefits 1,000,000 or 2,000,000 Lifetime benefit 1,000,000 renews to zero every two years in group plans. Deductible Clause

Means the policy holder will be expected to pay a certain percentage, usually 20-25. Out-of-pocket limits. After you pay $1000 the insurance company pays 100% in some coinsurance agreements. Coinsurance

Comprehensive Medical Policy Combines basic health care and major medical insurance One deductible Pay limits such as out-of-pocket limits coinsurance Comprehensive Medical Policy

Dental Insurance Helps pay for normal dental care. Such as: Exams | X-Rays | Cleaning | Fillings Complicated work: Root canals | Extractions False teeth | Braces Implants and jaw reconstruction may be covered under major medical. Group plans and cheap rates that everyone should have dental insurance. Dental Insurance

Vision Care Basic eye care Eye exams Prescription lenses Frames Contact lenses What’s not covered? Eye surgery | tinted lenses | coated lens Non prescription lenses | vision training Vision Care

Disability insurance protects you against the loss of income caused by a long illness or an accident. The insured receives weekly or monthly payments until that person is able to return to work. Disability

Short-term disability Long-term disability Permanent disability Short term – 3 to 12 months (Company Group) Long term – 8 to 24 months (Company Group) Permanent – more than 1 year or longer (Social Security Disability Benefits) Short-term disability Long-term disability Permanent disability

Health Insurance Providers Group Health Insurance Company – RUSD Union – UAW Organization – ARRP – NEA Cost savings compared to individual policies Health Insurance Providers

Individual Health Insurance Some people are not members of a group and not eligible for group insurance Self employed Expensive Require physical exam Have a waiting period Pre-existing conditions exclude some coverage (new laws in place to prohibit this activity) Individual Health Insurance

Managed Care Plans HMO – Health Maintenance Organizations Emphasize prevention Early detection and treatment Excludes cosmetic surgery Pre authorization for surgery or coverage is denied Not all hospitals are covered PPO – Preferred Provider Organizations POS – Point of Service Plans Larger insurance companies trying to control costs of rising health care. Patients have less control or choices over whom they see for health care. Managed Care Plans

When an insurance company requests that you obtain a second opinion for non-emergency procedures be sure to do so or your benefits may be reduced. Why might a managed plan ask you to get a second opinion? Managed Plans

State government assistance Workers compensation – provides medical and survivor benefits for injured, disabled, or killed on the job persons. Badger care – guarantees medical coverage for all Wisconsin children if not provided by company group plans or other health plans. Rates depend on family income levels. Medicaid – medical aid for low income families. State government assistance

Federal Government Assistance Medicare – health insurance for people age 65 and older. Hospital and medical. Extended young adult coverage – new law states than family insurance will provide coverage for young adults to up to age 25 through their parents group plans. Federal Government Assistance