1. Health Insurance
Chapter 41

2. 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…

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

4. 5 types of Medical Insurance
Hospital Surgical Regular Medical Major Medical Comprehensive Medical Policy

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

6. 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.

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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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