H EALTH I NSURANCE

B ASIC FACTS Healthcare costs continue to increase Even with insurance, consumers are asked to pay a larger amount of healthcare costs. 40% of the US citizens are uninsured One of the largest age groups uninsured is young people b/w ages 20 – 29

M OST C OMMON I NJURY ( MILD C ONCUSSION ) Physician$ Laboratory$ CAT Scan$1, X-Ray$ Emergency Room$ Physician (Urgent Care)$ Physician (Hospital)$ Radiologist$ Total$3,604.00

H EALTH I NSURANCE HOW IT WORKS : Law of Large Numbers (KT) Healthier Families. High Risk means no insurance or higher premiums Pre-existing Conditions (KT) Look at past months If possible conditions may not cover for a year or more Network & Non-Network Two basic Plan of insurance Group Plans Individual Plans

G ROUP I NSURANCE Everyone in group is covered. Usually offered through work, unions, religious organizations. Employer not required to offer Employer may pay part, or all of the insurance premiums, or none of the insurance premiums May cover employee but not dependents.

G ROUP I NSURANCE CONT.. Advantages: Less Expensive then individual plans Must enroll everyone, even if a dependent or someone has a pre-existing condition Cannot drop one person DisAdvantages May not be enough options May not be able to drop one particular person but can drop group Employer may stop to offer insurance if it drops entire group or does not offer to all.

I NDIVIDUAL P LAN. People who are self-employed or whose employers do not offer health insurance benefits. Buy directly from insurance company Advantages: Policy can be written to cover your specific needs Some insurance companies offer discounts for healthy families. DisAdvantages More expensive If you have a pre-existing condition will get charged more or refuse to enroll you.

M AKING S ENSE OF IT ALL Binding legal contract b/w the insured and insurer You must always be truthful in your dealings, if not then can void your policy Obama Care Was now (This means before insurance spending half, on health and more on CEO salary, Now spending more on health and less on CEO Salary Can’t deny for finding errors Co-payments (KT): small payment at the time of service

M AKING S ENSE OF IT ALL CONT … Co-payments (KT): small payment at the time of service Deductible (KT): what you have to pay first then depending on insurance 20%-80% Prescriptions $10, $20, $35 Underwriting Factors Age, health, occupation, habits, lifestyle,

M AKING S ENSE OF IT ALL CONT … Coverage to consider HospitalizationRehabilitaioin Facility Hospital outpatient servicesPhysical therapy Physician hospital visitsSpeech Therapy Office visitsHome health care Skilled Nursing testsHospice care Diagnostic TestMaternity Care Prescription drugsChiropractic Care Mental Health carePreventive care & checkups Drug & Alcohol abuse treatmentWell baby care ContraceptivesDental care Fertility treatmentsVision Care

M AKING S ENSE OF IT ALL CONT … Health insurance policies are usually written with a dollar maximum limits: per claim max or Lifetime limits Per claim max (KT): max amount the insurer will pay for any single claim. Lifetime Limits (KT): the dollar amount paid in claims over life and future. Also sometimes limits on certain things like $150 a day for hospitalization, $250 a day for intensive care.

T YPES OF I NSURANCE PLANS Fee-for-Service Plan (FFS) Managed Care Plan Health Maintenance Organization (HMO) Preferred Provider Organization (PPO)

F EE - FOR -S ERVICE P LAN (KT) Closets thing to the traditional type of insurance Traditional: you go to doctor and you pay. You can go to any doctor, lab, hospital, pharmacy you want and you share costs Usually after you satisfy deductible Most designate that it has to be reasonable and customary fee. What this means if a doctor over charges you will have to pay more

F EE - FOR -S ERVICE P LAN CONT.., Usually they put a cap on how much you pay out of pocket in a year. Advantage: Flexibility: you can choose any doctor, any hospital, and so forth. Disadvantage: Costs in premiums Cost of deductible higher And out-of-pocket payments above reasonable and customary fee.

M ANAGED C ARE P LAN (KT) Provides comprehensive medical care to members Members pay a set premium and can receive almost all care they need through the providers The managed care has preset physicians or providers that must be used. The key to this type of plan is volume. Physicians can charge reduced fees because they are guaranteed a certain number of patients.

H EALTH M AINTENANCE O RGANIZATION (HMO) ( KT ) Most common type of plan Physicians are employed by HMO which is known as primary care physician (PCP) (KT) HMO will not pay for specialists if PCP does not recommend. This means HMO will not pay for extra doctor visit is the PCP does not refer you to them IF you do see someone then you pay all. Also if you do have to see someone outside then they have to be in the Network or you pay

H EALTH M AINTENANCE O RGANIZATION (HMO) CONT … Advantages: Low costs Covers a wide range of preventive health improvement services Less paperwork Disadvantages: Main disadvantage is LACK OF FLEXIBILITY Covers a wide range of preventive health If a catastrophic or rare illness members may have difficulty receiving state of art care Exp Cancer

P REFERRED P ROVIDER O RGANIZATION (PPO) ( KT ) Combines HMO and FFS Physicians and other providers are listed in a network Can visit any provider in Network and pay small copayment No referral necessary to see specialists If out of network is seen still pays portion of bill You have to pay up front and ask for reimbursement PPO tend to cost more than HMO but less than FFS plans

C ONSOLIDATED O MNIBUS BUDGET REDUCTION A CT (COBRA) (KT) Give the employees or a company with 20 or more the right to continue their group coverage for 18 to 36 months depending on circumstances If you leave your job or are terminated *** Divorced from the covered employee If you work hours are reduced below minimum hours required Become eligible for Medicare Become disabled If employee of whom you are covered dies

C ONSOLIDATED O MNIBUS BUDGET REDUCTION A CT (COBRA) CONT … You have to pay both your premium and employers premium share if they paid If employers stops offering insurance or goes out of business then it stops for you. Varies from state to state

H EALTH I NSURANCE P ORTABILITY AND A CCOUNTABILITY A CT (HIPPA) ( KT ) Applies to all group health policies no matter what size, employer-based or not Covers individual policies sold by insurance companies or HMO’s You take your eligibility with you if you and only if your new employer offers health insurance Moving from one job w/insurance to new job w/insurance. Must cover any family member covered in last plan, cannot be rejected or charged higher premiums b/c of health problems.

M EDICAID Became law in 1963 under Social Security Act Medical assistants for eligible individuals with low income and resources Each state sets its own eligibility

M EDICARE Age 65 and over Have to fill out paperwork for it. They just don’t give it to you. If you miss the open enrollment then you don’t get benefits Plan A: free but you must pay % of hospital bills and pay a deductible & copay Plan B: covers parts of your non-hospital expenses. monthly premium, deductible, copayments, and small monthly premium

M EDICARE CONT … If you don’t enroll you still pay anyway. Most insurance companies won’t pay out what Medicare would have Medicare plan A & B does not cover everything so that is where Medigap (KT) came into play. You have 6 months open enrollment and if you don’t get then may refuse because of high risk health conditions.