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Understanding Health Insurance: Types, Costs, and Coverage Benefits

This guide provides an overview of health insurance, explaining critical terms such as premiums and deductibles. It elaborates on different health plans, specifically Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs), outlining their payment structures, provider access, and out-of-pocket expenses. You'll learn about example scenarios involving hospital visits, doctor appointments, and vision care, helping you assess the total medical expenses and insurance coverage. Mastering these concepts can aid in choosing the best health plan for your needs.

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Understanding Health Insurance: Types, Costs, and Coverage Benefits

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  1. Health Insurance - A plan which pays for part or all of a person’s medical costs

  2. PREMIUM: The amount you pay for insurance • DEDUCTIBLE: The amount you have to pay each year before insurance will kick in

  3. Health Maintenance Organizations(HMOs) • Pay Monthly premium • Few or no out of pocket expenses • See only physicians who have signed agreement with the HMO

  4. Preferred Provider Organizations(PPOs) • Members pay monthly premium • Providers (doctors) charge organization (insurance company) less than their regular fee for members to use • Can choose provider out of plan • Has higher out of pocket expense

  5. Practice (Pg. 71) • #1 Hospital = $3500 5 doc appointments @ $95 How much does he pay with his insurance? Cost= 20% Hospital + $15 (5 appointments) C= 0.20H + 5($15) (answer: D)

  6. Practice (Pg. 71) • #2 Eye Exam $100 Glasses $365 Insurance pays: $365- $100 = $265 (answer choice: A)

  7. Hernandez $243 per month 80% of hospital $15 per doc visit No Vision Gomez $405 per month All Hospital $10 per doc visit 100% Eye Exam $100 for glasses/ contacts #3 Coverages

  8. Medical Expenses 1 Year • $10,000 Hospital Stay • 12 Doctor trips • 4 Eye Exams @ $100 • 2 Glasses @ $300 each

  9. Hernandez __________ Hospital ___________Doc Visit ___________Vision ___________Glasses ____________TOTAL _________ insurance _________ med expense _________ Total Out of Pocket Hernandez

  10. Gomez __________ Hospital ___________Doc Visit ___________Vision ___________Glasses ____________TOTAL _________ insurance _________ med expense _________ Total Out of Pocket Gomez

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