Health Insurance

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Health Insurance

• Can name some carriers???
• http//www.healthinsurancesort.com/carrier-list.ht
  m

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Insurance

• A person buys insurance and the insurance
  provider agrees to pay or reimburse for the costs
  of medical care
• Babylon (1750 BC) merchant ships
• Great Fire on London (1666)
• 13,200 houses were burned to the ground
• Gambling analogy
• In 2006, there were 47 million people in the U.S.
  (16 of the population) who were without health
  insurance for at least part of that year

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Different Types of Insurance

• Hospitalization Insurance- Specifically pays for
  hospitalization
• Surgical Insurance Specifically pays for fees
  associated with surgery
• Disability Insurance Pays for loss of income
  due to accident or illness
• Usually only a percentage of your salary
• Life Insurance
• Car Insurance
• Alien abduction insurance??????

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History of Health Insurance

• Before the development of medical expense
  insurance, patients were expected to pay all
  other health care costs out of their own pockets
• Almost impossible now with the high cost of
  health care
• Accident insurance was first offered in the
  United States by the Franklin Health Assurance
  Company of Massachusetts. This firm, founded in
  1850, offered insurance against injuries arising
  from railroad and steamboat accidents
• The first employer-sponsored group disability
  policy was issued in 1911

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Group vs. Individual Insurance

• Group Policies provided by employer
• you employer pays for all or most of you
  insurance plans cost
• All of the employees at you work have the same
  health insurance options as you do
• Commonly called benefits

• Individual Policies you buy the policy yourself
• Very similar to the way you get car insurance
• About 9 of the population gets their health
  insurance this way

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Health Insurance Terms

• Provider a hospital, doctor or anyone else who
  provides a service
• Network Group of hospitals and/or doctors that
  jointly provide care to a given group of patients
  covered by health insurance
• Major Medical - form of medical insurance
  designed to supplement a basic medical expense
  plan in the event of extraordinary medical
  expenses
• Extreme illness or disability
• Covered Expense something that the insurance
  plan will pay for
• Exclusions Not all services are covered. The
  policy-holder is generally expected to pay the
  full cost of non-covered services out of their
  own pocket.

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Insurance Terms Continued

• Pre-existing Condition A health Problem that a
  person has before they are covered by a certain
  policy
• The policy may or may not pay for expenses
  associated with these conditions
• Waiting Period Predetermined amount of time
  between when your employment begins and when your
  insurance coverage actually begins
• You are not covered during this time

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Your Costs

• Premium The amount the policy-holder pays to
  the health plan each month to purchase health
  coverage
• Deductible -The amount that the policy-holder
  must pay out-of-pocket before the health plan
  pays its share
• Deductible could be yearly or could be per injury
  / illness
• Example
• Your yearly deductible - 500.00
• Your medical Bill 2,500.00
• Insurance company pays 2,000.00
• You pay 500.00
• Copayment The amount that the policy-holder must
  pay out of pocket before the health plan pays for
  a particular visit or service.
• For example, a policy-holder might pay a 45
  copayment for a doctor's visit, or to obtain a
  prescription.
• A copayment must be paid each time a particular
  service is obtained

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Example of what a plan would look like

• http//www.tffhp.org/summary_plan_description.htm

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Managed Care

• Organized system of health care services designed
  to control health care costs
• One of the most characteristic forms of managed
  care is the use of a panel or network of health
  care providers to provide care to enrollees
• Managed care usually involves
• Standards for selecting providers
• An emphasis on preventive care
• Financial incentives to encourage enrollees to
  use care efficiently

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Two main kinds of Managed Care Insurance

• HMO Health Maintenance Organization
• PPO Preferred Provider Organization

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HMO

• HMOs manage their patients' health care by
  reducing unnecessary services
• To achieve this, most HMOs require members to
  select a primary care physician (PCP)
• This physician acts a a gatekeeper to medical
  services
• most medical needs must first go through the PCP,
  who authorizes referrals to specialists or other
  doctors if deemed necessary
• This is called a referral
• Emergency medical care does not require prior
  authorization from a PCP

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HMOs and non-network

• Most HMOs will only pay for medical bills for
  you PCP of for services your PCP approves through
  referral
• HMOs typically provide no coverage for care
  received from non-network physicians (with
  exceptions for emergency care while traveling,
  etc.).

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HMO Public Image

• HMOs often have a negative public image due to
  their restrictive appearance.
• HMOs have been the target of lawsuits claiming
  that the restrictions of the HMO prevented
  necessary care
• Usually a cheaper plan

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PPO Preferred Provider Organization

• Organization of medical doctors, hospitals and
  other health care providers
• network or preferred provider
• Network is contracted with an insurer to provide
  health care coverage at a reduced rate
  (substantial discount)
• Some surgeries or procedures may need to require
  pre-approval by the insurance company

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PPOs and non-network

• PPO may reimburse 90 percent of costs for care
  received within the network, but only 70 percent
  of costs for non-network care

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PPO Public Image

• Usually allow more freedom than HMO
• Usually a more expensive type of insurance plan
• Networks can change
• If you choose to get medical care from a provider
  who is out of network.It costs you more money

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Federal Programs for Health Coverage

• Medicaid health insurance for people with lower
  incomes
• Funded by state and federal government
• Eligibility rule vary state to state
• Example of Medicaid requirements
• You're a pregnant woman who meets income
  requirements. For example, a family of four
  making 23,225 a year or less qualifies.
• Your family's assets are less than 2,000

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Federal Programs for Health Coverage

• Medicare Government health coverage for people
  65 years or older
• In many cases Medicare pays a portion of the
  persons health care cost. The rest is paid by
  the persons Medicaid or supplemental insurance
  plan

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WIC

• Women Infants and Children
• Program that helps mothers and children with
  medical bills
• Prenatal care
• Preventive screenings
• Immunizations
• Pay for proper food and medicines

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Single Payer System

• National Health Care
• Centrally controlled heath care system
  (government)
• Taxes
• Sometime requires supplemental health insurance
• U.S. ranks
• 22nd in infant mortality
• 46th in life expectancy
• 37th in health system performance, between Costa
  Rica and Slovenia

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Bad system or Broken System?

• In a 2007 comparison by the Commonwealth Fund of
  health care in the U.S. with that of Germany,
  Britain, Australia, New Zealand, and Canada, the
  U.S. ranked last on measures of quality, access,
  efficiency, equity, and outcomes
• 30 percent of U.S. health care dollars, or more
  than 1,000 per person per year, went to health
  care administrative costs

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Federal Programs for Health Coverage

• COBRA
• Consolidated Omnibus Budget Reconciliation Act
  (1985)
• If you lose your job you may continue to pay your
  insurance premium and maintain coverage for up to
  18 months
• This also applies to children on insured
  employees
• If a child somehow looses full-time student
  status that child may make a COBR payment to
  maintain coverage

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• Coinsurance Instead of paying a fixed amount up
  front (a copayment), the policy-holder must pay a
  percentage of the total cost.
• For example, the member might have to pay 20 of
  the cost of a surgery, while the health plan pays
  the other 80. Because there is no upper limit on
  coinsurance, the policy-holder can end up owing
  very little, or a significant amount, depending
  on the actual costs of the services they obtain.

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Sicko

• http//www.youtube.com/watch?vxlDAUKSh9CQ