Health Insurance

1. Health Insurance

2. Basic facts • Healthcare costs continue to increase • Even with insurance, consumers are asked to pay a larger amount of healthcare costs. • 40% of the US citizens are uninsured • One of the largest age groups uninsured is young people b/w ages 20 – 29

3. Most Common Injury (mild Concussion) • Physician $186.00 • Laboratory $156.00 • CAT Scan $1,444.00 • X-Ray $461.00 • Emergency Room $359.00 • Physician (Urgent Care) $186.00 • Physician (Hospital) $410.00 • Radiologist $282.00 • Total $3,604.00

4. Health Insurance how it works: • Law of Large Numbers (KT) • Healthier Families. • High Risk means no insurance or higher premiums • Pre-existing Conditions (KT) • Look at past 6 -12 months • If possible conditions may not cover for a year or more • Network & Non-Network • Two basic Plan of insurance • Group Plans • Individual Plans

5. Group Insurance • Everyone in group is covered. • Usually offered through work, unions, religious organizations. • Employer not required to offer • Employer may pay part, or all of the insurance premiums, or none of the insurance premiums • May cover employee but not dependents.

6. Group Insurance cont.. • Advantages: • Less Expensivethen individual plans • Must enroll everyone, even if a dependent or someone has a pre-existing condition • Cannot drop one person • DisAdvantages • May not be enough options • May not be able to drop one particular person but can drop group • Employer may stop to offer insurance if it drops entire group or does not offer to all.

7. Individual Plan. • People who are self-employed or whose employers do not offer health insurance benefits. • Buy directly from insurance company • Advantages: • Policy can be written to cover your specific needs • Some insurance companies offer discounts for healthy families. • DisAdvantages • More expensive • If you have a pre-existing condition will get charged more or refuse to enroll you.

8. Making Sense of it ALL • Binding legal contract b/w the insured and insurer • You must always be truthful in your dealings, if not then can void your policy • Obama Care • Obama Care • Was 40-80 now 80-40 (This means before insurance spending half, on health and more on CEO salary, Now spending more on health and less on CEO Salary • Can’t deny for finding errors • Co-payments (KT): small payment at the time of service

9. Making Sense of it ALL cont… • Co-payments (KT): small payment at the time of service • Deductible (KT): what you have to pay first then depending on insurance 20%-80% • Prescriptions $10, $20, $35 • Underwriting Factors • Age, health, occupation, habits, lifestyle,

10. Making Sense of it ALL cont… • Coverage to consider

11. Making Sense of it ALL cont… • Health insurance policies are usually written with a dollar maximum limits: per claim max or Lifetime limits • Per claim max (KT): max amount the insurer will pay for any single claim. • Lifetime Limits (KT): the dollar amount paid in claims over life and future. • Also sometimes limits on certain things like $150 a day for hospitalization, $250 a day for intensive care.

12. Types of Insurance plans • Fee-for-Service Plan (FFS) • Managed Care Plan • Health Maintenance Organization (HMO) • Preferred Provider Organization (PPO)

13. Fee-for-Service Plan (KT) • Closets thing to the traditional type of insurance • Traditional: you go to doctor and you pay. • You can go to any doctor, lab, hospital, pharmacy you want and you share costs • Usually 20-80 after you satisfy deductible • Most designate that it has to be reasonable and customary fee. • What this means if a doctor over charges you will have to pay more

14. Fee-for-Service Plan cont.., • Usually they put a cap on how much you pay out of pocket in a year. • Advantage: • Flexibility: you can choose any doctor, any hospital, and so forth. • Disadvantage: • Costs in premiums • Cost of deductible higher • And out-of-pocket payments above reasonable and customary fee.

15. Managed Care Plan (KT) • Provides comprehensive medical care to members • Members pay a set premium and can receive almost all care they need through the providers • The managed care has preset physicians or providers that must be used. • The key to this type of plan is volume. • Physicians can charge reduced fees because they are guaranteed a certain number of patients.

16. Health Maintenance Organization (HMO) (kt) • Most common type of plan • Physicians are employed by HMO which is known as primary care physician (PCP) (KT) • HMO will not pay for specialists if PCP does not recommend. • This means HMO will not pay for extra doctor visit is the PCP does not refer you to them • IF you do see someone then you pay all. • Also if you do have to see someone outside then they have to be in the Network or you pay

17. Health Maintenance Organization (HMO) cont… • Advantages: • Low costs • Covers a wide range of preventive health improvement services • Less paperwork • Disadvantages: • Main disadvantage is LACK OF FLEXIBILITY • Covers a wide range of preventive health • If a catastrophic or rare illness members may have difficulty receiving state of art care • Exp Cancer

18. Preferred Provider Organization (PPO) (kt) • Combines HMO and FFS • Physicians and other providers are listed in a network • Can visit any provider in Network and pay small copayment • No referral necessary to see specialists • If out of network is seen still pays portion of bill • You have to pay up front and ask for reimbursement • PPO tend to cost more than HMO but less than FFS plans

19. Consolidated Omnibus budget reduction Act (COBRA) (KT) • Give the employees or a company with 20 or more the right to continue their group coverage for 18 to 36 months depending on circumstances • If you leave your job or are terminated *** • Divorced from the covered employee • If you work hours are reduced below minimum hours required • Become eligible for Medicare • Become disabled • If employee of whom you are covered dies

20. Consolidated Omnibus budget reduction Act (COBRA) cont… • You have to pay both your premium and employers premium share if they paid • If employers stops offering insurance or goes out of business then it stops for you. • Varies from state to state

21. Health Insurance Portability and Accountability Act (HIPPA) (kt) • Applies to all group health policies no matter what size, employer-based or not • Covers individual policies sold by insurance companies or HMO’s • You take your eligibility with you if you and only if your new employer offers health insurance • Moving from one job w/insurance to new job w/insurance. • Must cover any family member covered in last plan, cannot be rejected or charged higher premiums b/c of health problems.

22. Medicaid • Became law in 1963 under Social Security Act • Medical assistants for eligible individuals with low income and resources • Each state sets its own eligibility

23. Medicare • Age 65 and over • Have to fill out paperwork for it. • They just don’t give it to you. If you miss the open enrollment then you don’t get benefits • Plan A: free but you must pay % of hospital bills and pay a deductible & copay • Plan B: covers parts of your non-hospital expenses. monthly premium, deductible, copayments, and small monthly premium

24. Medicare cont… • If you don’t enroll you still pay anyway. Most insurance companies won’t pay out what Medicare would have • Medicare plan A & B does not cover everything so that is where Medigap (KT) came into play. • You have 6 months open enrollment and if you don’t get then may refuse because of high risk health conditions.