1. Healthcare Finances
HS II Unit 1.03

2. Health Care Finances (2 Forms)
Government Finance
Private Finance

3. Government Finances Funded by Taxes Include: Medicare Medigap Medicaid
Tricare
VHA (Veteran Health Administration)

4. Medicare
Government payment for healthcare for patients over 65, any person with a disability that has received social security benefits for at least 2 years, or anyone with end stage renal disease

5. Medicare Plans 4 Parts: A- Hospital Care B- Outpatient Medical Care
C- Advantage Plan
D-Medication

6. Medicare (Plan A) The original Medicare plan
Automatically enrolled unless the patient specifically enrolls in a Medicare Advantage Plan (Part C)
Fee-for service
Pay a deductible and co-pay

7. Medicare (Part A) Hospital insurance at no cost to most people
Coverage includes Inpatient Care:
Skilled nursing facilities
Critical Access Hospitals
Hospitals
Hospice
Home Health

8. Medicare (Part B) Pays for necessary medical services and supplies
Most people pay a premium for Plan B
Covers:
Outpatient Care
Doctor’s Services
Physical or Occupational Therapies
Additional Home Healthcare

9. Medicare (Plan C) Combination of Part A and Part B
Provided through private insurance companies approved by Medicare
Option add Part D
Include:
HMOS, PPOs, Private fee-for-service plans
Medicare special needs

10. Medicare (Part D) Stand-alone prescription drug coverage
Most people pay a premium
Plans vary and cover different drugs
Can choose the best plan for patient’s need

11. Video on Medicare (ABCD)

12. Medigap
A private insurance policy that pays the difference between the medical charge and the amount that Medicare pays
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13. Medicaid Government payment of healthcare services for people with:
low income
children who qualify for services
people who are disabled or blind
Funded by federal government but regulated by individual state government
Not all people with low income qualify

14. Medicaid Video

15. Tricare
Military health plan that provides services for active duty personnel and their families, survivors of military personnel and retired military personnel and their families

16. Veterans Health Administration
Provides healthcare services to anyone who served in the military

17. Private Finances Private Insurance Group Insurance Plan Includes
The insured pays a monthly premium for insurance plan
Group Insurance Plan
The insured and usually their employer share the amount of the premium
Includes
HMOs
PPOs
Indemnity Plan
Out of Pocket
Workers’ Compensation

18. Health Maintenance Organization (HMO)
Insurance method that focuses on prevention of disease, must see providers from an approved list
Care is directed toward prevention of disease
Patient must see only HMO approved providers
Pay a monthly fee, no additional charge for care
Care from non-HMO provider generally not covered

19. HMO Video

20. Preferred Provider Organization (PPO)
Group of healthcare providers that provide services to a specific group, often at a reduced rate
Group of doctors and/or hospitals that provide care to a specific group
PPO provides services to the insured at a reduced rate
Usually require a deductible and a co-pay
Less coverage for treatment provided by non-PPO provider

21. PPO vs. HMO

22. Indemnity Plan
Traditional Plan with freedom to visit- physician of choice
No referral required by insurance company
“Pay” up front
Get reimbursed amount allowed by insurance policy (amounts may vary)

23. Out of Pocket
Cash
Medical bill that is not covered by insurance and must be paid by the patient

24. Worker’s Compensation
Health insurance plan that pays for the healthcare of workers injured on the the job

25. Key Finance Terms
Co-insurance: the percentage of the bill for services that the policy holder must pay
Co-payment (co-pay): a specific amount paid by the patient for each medical service, such as a $15 for each doctor visit or each prescription filled
Deductible: amount the patient must pay before the insurance starts to pay for services

26. Key Finance Terms
Out-of-Pocket: medical bill that is covered by insurance and must be paid by the patient
Premium: the periodic amount paid to an insurance company for healthcare or prescription drugs
Reimbursement: amount paid to patient toward the cost of healthcare services