1. Health Insurance Plans Intro to Health Science Unit One Lesson 5 Diversified Health Occupations pages

2. Objective  Compare basic principles of at least four different health insurance plans

3. Introduction  Cost of healthcare is a major concern of everyone who needs health services  Health care costs are increasing much faster than other costs of living  Most people rely on health insurance plans to pay for health care costs  Without insurance the cost of an illness can become a financial disaster  Most people rely on health insurance plans to pay for health care costs, and there are many different types of these plans

4. Health Insurance Plans  Offered by thousands of insurance agencies  Popular example Blue Cross-Blue Shield  Premium or payment made to insurance company  If insured individual has expenses covered by the plan, the insurance company pays for the services  Amount of payment and services covered vary from plan to plan

5. Insurance Terminology Amount that must be paid by insured individual for medical services Must be paid before the policy begins to pay Deductible Specific amount of money patient pays for a particular service Example: $10 each physician visit regardless of total cost of visit Co- Payment requires that specific percentages of expenses are shared by individual and company 80-20%: insurance pays 80% you pay 20% 50-50%: insurance pays 50%, you pay 50% Co- Insurance

6. Health Insurance Plans  Many individuals have insurance from place of employment  At times employer pays entire cost of plan  Other times, cost is shared by employer and employee  Private policies can also be purchased by individuals

7. Health Insurance Plans HMO PPO Medicare Medicaid US Government Plans Workman’s Compensation

8. Health Maintenance Organizations (HMOs)  Special type of insurance plan  Monthly fee or premium paid for membership and fee stays the same regardless of amount of health care used  Premium can be paid by employer and/or individual  Most pay for total health care including routine exams and preventative type of care, not usually covered under other insurance plans

9. HMO’s  Advantages  Provides readily access to health care  Early detection and treatment  Individual maintains better state of health  Disadvantages  Individual can only use certain HMO affiliates (doctors, labs, hospitals)  If individual chooses nonaffiliated health care provider, the individual must pay for the care

10. Preferred Provider Organizations (PPOs)  Usually provided by large industry or company  Industry/company contracts with certain health care agencies  Employee restricted to using the specific health care agencies  Industry/company can provide health care at lower rates

11. Medicare  Federal government heath care plan  Provides coverage to the following individuals:  Over age 65  Persons with disability who have had social security benefits for at least two years

12. Medicare Continued Type A * Covers hospital services * Covers care by extended care facility or home health care after hospitalization Type B * Coverage for doctor's services, outpatient treatments, therapy, and other health care * Individual pays premium for this coverage * 80-20% co insurance

13. Medicaid  Medical assistance program operated by individual states  Benefits and individuals covered vary from state to state  Usually covers individuals with low incomes, children who qualify or public assistance, and individuals who are physically disabled or blind.

14. Workers Compensation  Provides treatment for workers injured on the job  Administered by the state  Payments made by employers and the state  Provides payment for health care and lost wages

15. United States Government Plans  Provide health care for all military personnel  TRICARE(formally CHAMPUS)  Care for ALL active duty members and families  Care for survivors of military personnel and retired members of the armed forces  Veterans Administration

16. Managed Care  Developed because of rising cost of health care  Employers and insurance companies want to see that money is spent efficiently rather than wastefully  Principle is that all health care provided to patient must have a purpose  Second opinion or verification of need is frequently required

17. Managed Care Continued  Every effort is made to provide preventative care and early diagnosis of disease  Usually provides routine physical exams, well baby care, immunizations, and wellness education to promote good nutrition, exercise, weight control, and healthy living practices

18. Managed Care Continued  Employers and Insurance companies create a network of doctors, specialists, therapists, and health care facilities that will provide care at the most reasonable cost  HMOs and PPOs are main providers  Private insurance companies set up health care networks  Networks compete for consumer dollar and are required to provide quality care at lowest possible cost  Health care consumer receives quality care at most reasonable cost, but is restricted in choice of health care providers

19. Review  Health insurance plans  DO NOT solve all problems of health care cost  DO help many people pay for all or part of cost  It is important to understand  what your plan covers  Co insurance and other restrictions your plan may have

20. Check for Understanding What is an advantage of HMOs? What type of plan restricts individuals to the use of certain health care facilities? What plan provides insurance to individuals over 65 years of age ? Who pays the premium for private health care insurance? What does a 75-25 percent co insurance mean?