Health Insurance Mr. Peterson. st=PLAEF1F13C29ACCC01&index=1&feature=plpp_vide o

Health InsuranceMr. Peterson

http://www.youtube.com/watch?v=nXfGeMNnBsM&list=PLAEF1F13C29ACCC01&index=1&feature=plpp_video

Video

Protect against economic loss in the event of serious accidents or illnesses.

Protect against the rising cost of health care, which is outpacing other costs in general.

Importance of Health Insurance

Private Insurance Available to individuals or families Provided as group health insurance plans

through various employers Government Health Insurance Plans

Medicare Medicaid

Workers’ Compensation

What are my options?

Fee-for-service plans (Indemnity) Pay deductible plus a percentage of eligible

costs before insurance will pay 80/20 Co-pay Pays for medical tests and prescription drugs

as well as hospital and doctor fees

Private Insurance

Managed Care Plans Contract with specific doctors and other health

care providers Charge monthly fees plus small co-payments

for service No deductible Health Maintenance Organizations (HMOs) Preferred Provider Organizations (PPOs)

Private Insurance

Provide a list of participating doctors Must go through primary care doctor for

other treatments Go outside the plan, pay the bill

Health Maintenance Organizations (HMOs)

Insurance company or provider contracts with network of physicians and hospitals

Network agrees to accept a negotiated fee for services provided to PPO customers

Lower cost to stay in network

Preferred Provider Organizations (PPOs)

Primary care doctor supervises plan and makes referrals

Pay more for nonparticipating specialists

Point-of-service (POS) plans

Premiums Amount you or your employer pay monthly

Co-insurance Amount or share of the costs you must pay for

services 20% up to a stated annual maximum

Deductible

Indemnity and Managed Care

Preauthorization Utilization Reviews

Assessment of appropriateness and necessity Pre-existing conditions Renewability

Indemnity and Managed Care

Maximum Benefits Open enrollment period

Enroll in plan or change coverage options Exclusions

Mental health care, dental, etc…

Indemnity and Managed Care

Coverage Benefit packages and care providers Premiums and deductible Uncovered costs Conversion to individual plan

Choosing a Plan

Consolidated Omnibus Budget Reconciliation Act At your expense, you can continue your

previous employer’s coverage for up to 18 months after you leave the job.

WHY DOES THIS MATTER?

COBRA

How the Most Common Types of Health Plans Compare

Which would you rather have?

Medicare 65 and older (disabled individuals under 65) Health insurance administered by Social

Security Funded by payroll taxes paid by employers,

employees (half premium), and the self-employed (full premium)

Covers inpatient for 150 days

Government Health Insurance Plans

Part A- Basic hospital coverage (deductible) Provided free for those who qualify Covers hospital room and board Deductibles apply

Part B – Supplementary medical insurance Optional for a monthly premium if eligible for Part

A Covers doctors and surgeons, lab tests, x-rays,

and possibly some home health care. Financed by government and monthly premiums

Medicare

State administered for people of low economic means

Federal government funded with state and local tax

Eligibility and levels of coverage vary by state Home health care Dental and eye care Prescription drugs

Medicaid

Mandatory health insurance that compensates workers for job-related illness or injury.

Premiums paid by employers. Premiums based on merit; employers who

file the most claims pay the highest rates State administered; coverage varies.

How does this compare to the others?

Workers’ Comp

Insured’s health Family health history Occupation or hobbies Gender

Women live longer, and in turn pay less. Why? Age of insured

Pay more as you get older. Why?

Factors Affecting Cost

http://www.inc.com/magazine/20051101/handson-case-study.html

Real Life Scenario

Get into groups of 2 or 3. Discuss each of the following cases.

Would you accept or decline the person in the case?

Why or why not? Would you make this person pay more or less?

Group Time

26 years old Male Previous family history of heart problems No major medical surgeries Works in a mine

Case 1

Female 45 years of age Chain smoker Librarian No history of major family issues Clean bill of health

Case 2

Male 35 years of age Falls under the definition of obese Works a minimum wage job Had a major illness when 12 No family history of illnesses

Case 3

Female 53 years old Family history of cancer Works in a car factory Clean bill of health

Case 4