1. Health Care Finance Can You Afford To Be Sick??

2. Journal Question If you are critically injured in an accident, would the type of life-saving care you receive in the ER be dependent on whether or not you have medical insurance? What about when you are recovering, would the type of care you get be dependent on whether you have medical insurance?

3. Fact Sheet Many people in the US are uninsured – assume all responsibility for health care cost. Number was 50.7 million in 2010 in a population of 310 million

4. Why Have Insurance?? Decreases cost of health care Increases access to health care

5. Types of Insurance: Employer Provided Eligibility depends upon continuous employment May only be provided to full time or 40 hour per week employees or may be offered to part-time 20 hour per week employees at an increased cost. Some companies have a waiting period before insurance benefits are available. These are usually the most economical plans as employers may subsidize part or all of costs for employee – trends are a decrease in these benefits.

6. Types of Insurance: Self-Insured Many persons who are self-employed or that work for small business employers must purchase their own health insurance plans These plans usually are much more expensive than employer based programs

7. Health Insurance Terms Two types of purchased group insurance plans: HMO – Health Maintenance Organization PPO – Preferred Provider Organization HMO - Care to be provided by selected health care provider groups that work directly for or are contracted with the HMO. PPO – Care to be provided by Physicians/Health Care Providers that have signed a contract with plan to provide services at a reduced rate. These providers are listed as preferred providers. The insured person chooses from preferred providers

8. Health Insurance Terms HMO – Health Maintenance Organization Positives: As it is more profit for the HMO if you use less health care dollars, they are more likely to pay for preventative care and screenings, health promotion. Also premiums are usually cheaper. Negatives: More difficult to get to specialty care, limited to choice of provides in HMO, tight controls on amount & type of care approved

9. Health Insurance Terms Premium – the amount paid to an insurance company each month to have coverage. Co-payment – a set amount you pay for each office visit, prescription filled. Insurance company pays the rest. Deductible – the amount you must pay out of pocket before insurance begins to pay for certain services.

10. Additional Health Insurance Facts Primary Care Provider – physician designated as “gate keeper” for a health care plan. Usually a general practice physician such as family practice, pediatrician, or internist Co-Insurance - after deductible is met, the health plan will pay different percentages of health care cost – for example they will pay 80% of costs and you pay 20% Some plans have life-time maximums for benefits Prescription drug coverage may or not be included in a health care plan.

11. Additional Insurance Cancer Insurance Specific insurance for the treatment of cancers. Additional to basic health care insurance.

12. Disability Insurance Provides income upon disability – short or long term. Would provide a percentage of your income while you were unable to work. Various waiting periods are available before benefits begin. Shorter waits = higher premiums.

13. Dental/Vision Insurance Often Vision/Dental not included in traditional health insurance plans and must be paid for separately. Vision may pay a portion of an eye exam and glasses or contact lenses cost. Dental may cover a portion of dental & orthodontic care.

14. Life Insurance Provides financial payment to a beneficiary in the event of death. A beneficiary is the person that you designate to receive your life insurance benefit. Employers often offer life insurance to their employees in the amount of the employee's annual salary for free – additional can be purchased for a premium. Individual policies can also be purchased. Premiums depend on how much insurance benefit you want and also on your age, health status, even smoking and weight. A physical exam may be required. You can be denied coverage!

15. Types of Life Insurance Term Life Insurance – specific amount of money will be paid to a beneficiary Whole Life Insurance – a policy that allows the holder of the policy to draw on the insurance as a pension as well as having money go to a beneficiary at the time of death

16. Types of Insurance: Government Medicare - Federal Military and Veteran’s Care – Federal Worker’s Compensation – State/Employer Medicaid – State/Federal Program

17. Medicare Federal insurance plan for Americans 65 and over and many adults with disabilities or Renal (kidney) failure Part A – covers hospital care, skilled nursing, home health & hospice care. No premiums – some deductible, co-pays depending on length of care Part B -covers doctors office, ambulance, medical equipment, lab, x-ray,etc. Does have small monthly premium, small deductible and 20% co-insurance

18. Medicare Part C – Medicare Advantage Plans offered by government approved private insurance companies. Part D – covers prescription drugs. Monthly premiums and co-pays apply

19. Medicare Medicare sets limits on amounts that it will pay for services provided to it’s participants Used since 1983, DRG’s or Diagnostic Related Groups have been used to help determine payment for given procedures. This means reimbursement is not based on actual charges but on average cost of care for that particular diagnosis/procedure

20. Military and Veteran’s Health Care Health care provided for active military and retired military personnel through Tri-Care insurance program or through VA (Veteran’s Administration) System. If care is gotten through VA, no cost or limited cost to veteran.

21. Worker’s Compensation States and employers jointly provide coverage for worker’s. Would provide medical expense coverage and wage replacement for lost work time for an on the job injury.

22. Medicaid Matching funds state/federal program that provides health care coverage at no cost or reduced cost based on household income. Income/asset guidelines set by state. These guidelines are based on federal poverty guidelines Also may supplement coverage for those on Medicare that meet income & asset guidelines, cover foster children, uninsured pregnant teens. Pays lower reimbursement than private insurance so not accepted by all providers.

23. What did HIPAA do for health insurance consumers? HIPAA – Health Insurance Portability and Accountability Act Enacted 1996 Prevents group plans from discriminating against individuals based on disability, health/medical history, genetic information Limits ability of group & individual plans to limit coverage based on “pre-existing conditions”

24. What did HIPAA do for everyone receiving health care? Mandated strict guidelines for the access and use of consumer health records and billing records. Designed to protect the privacy of everyone receiving health care Failure to follow guidelines can result in large fines for health care agencies and individual health care workers

25. Insurance Situation Problem You fall and injure your knee. You see an orthopedic surgeon in his office who orders a MRI of your knee. After reviewing the MRI, the orthopedist tells you that an arthroscopy is necessary to repair a torn ligament. You have the procedure at a local hospital and recover at home with a prescription for pain medication and antibiotics.

26. Insurance Situation Problem Your insurance plan pays based on the following: Specialist office visits: $30 co-pay Outpatient testing: 80% after $500 deductible met Outpatient surgery & associated fees: 80% after $500 deductible met Medication prescriptions: $15 co-pay generic, $30 co-pay brand name

27. Insurance Situation Problem The charges for your care were as follows: Orthopedic office visit $150 MRI $1600 Hospital fee $7000 Orthopedic Surgeon’s Procedure fee $2000 Anesthesia fee $1200 Radiologist fee $250 Pathologist fee $200 Generic Pain medication $30 Brand Name antibiotic $150

28. Insurance Situation Problem How much would you have to pay without an insurance plan? How much will you pay for this care with your insurance plan? Better to have insurance????

29. Insurance Scenario #2 You pay $100 per month in health care premiums. You only have one health care related event this year – a broken arm with total treatment cost of $1200 without insurance and $300 with insurance. Did insurance “save” you any money?