Health InsuranceHealth Insurance

Can name some carriers???Can name some carriers???

http://www.healthinsurancesort.cohttp://www.healthinsurancesort.com/carrier-list.htmm/carrier-list.htm

InsuranceInsurance

A person buys insurance and the insurance A person buys insurance and the insurance provider agrees to pay or reimburse for the costs provider agrees to pay or reimburse for the costs of medical careof medical care

Babylon (1750 BC) – merchant shipsBabylon (1750 BC) – merchant ships Great Fire on London (1666) Great Fire on London (1666)

13,200 houses were burned to the ground13,200 houses were burned to the ground Gambling analogyGambling analogy In 2006, there were 47 million people in the U.S. In 2006, there were 47 million people in the U.S.

(16% of the population) who were without health (16% of the population) who were without health insurance for at least part of that year insurance for at least part of that year

Different Types of InsuranceDifferent Types of Insurance

Hospitalization Insurance- Specifically pays for Hospitalization Insurance- Specifically pays for hospitalization hospitalization

Surgical Insurance – Specifically pays for fees Surgical Insurance – Specifically pays for fees associated with surgeryassociated with surgery

Disability Insurance – Pays for loss of income Disability Insurance – Pays for loss of income due to accident or illnessdue to accident or illness Usually only a percentage of your salaryUsually only a percentage of your salary

Life InsuranceLife Insurance Car InsuranceCar Insurance Alien abduction insurance??????Alien abduction insurance??????

History of Health InsuranceHistory of Health Insurance

Before the development of medical expense Before the development of medical expense insurance, patients were expected to pay all insurance, patients were expected to pay all other health care costs out of their own pockets other health care costs out of their own pockets Almost impossible now with the high cost of health Almost impossible now with the high cost of health

carecare Accident insurance was first offered in the Accident insurance was first offered in the

United States by the Franklin Health Assurance United States by the Franklin Health Assurance Company of Massachusetts. This firm, founded Company of Massachusetts. This firm, founded in 1850, offered insurance against injuries in 1850, offered insurance against injuries arising from railroad and steamboat accidents arising from railroad and steamboat accidents

The first employer-sponsored group disability The first employer-sponsored group disability policy was issued in 1911 policy was issued in 1911

Group vs. Individual InsuranceGroup vs. Individual Insurance

Group PoliciesGroup Policies – – provided by employerprovided by employer you employer pays for you employer pays for

all or most of you all or most of you insurance plans costinsurance plans cost

All of the employees All of the employees at you work have the at you work have the same health same health insurance options as insurance options as you doyou do

Commonly called Commonly called “benefits“benefits

Individual PoliciesIndividual Policies – – you buy the policy you buy the policy yourselfyourself Very similar to the way Very similar to the way

you get car insuranceyou get car insurance About 9% of the About 9% of the

population gets their population gets their health insurance this health insurance this wayway

Health Insurance TermsHealth Insurance Terms Provider Provider – a hospital, doctor or anyone else who – a hospital, doctor or anyone else who

provides a serviceprovides a service NetworkNetwork – Group of hospitals and/or doctors that jointly – Group of hospitals and/or doctors that jointly

provide care to a given group of patients covered by provide care to a given group of patients covered by health insurance health insurance

Major MedicalMajor Medical - form of medical insurance designed to - form of medical insurance designed to supplement a basic medical expense plan in the event of supplement a basic medical expense plan in the event of extraordinary medical expenses extraordinary medical expenses

Extreme illness or disabilityExtreme illness or disability Covered ExpenseCovered Expense – something that the insurance plan – something that the insurance plan

will pay forwill pay for ExclusionsExclusions –Not all services are covered. The policy- –Not all services are covered. The policy-

holder is generally expected to pay the full cost of non-holder is generally expected to pay the full cost of non-covered services out of their own pocket. covered services out of their own pocket.

Insurance Terms ContinuedInsurance Terms Continued

Pre-existing ConditionPre-existing Condition – A health Problem that – A health Problem that a person has before they are covered by a a person has before they are covered by a certain policycertain policy The policy may or may not pay for expenses The policy may or may not pay for expenses

associated with these conditionsassociated with these conditions

Waiting PeriodWaiting Period – Predetermined amount of time – Predetermined amount of time between when your employment begins and between when your employment begins and when your insurance coverage actually beginswhen your insurance coverage actually begins You are not covered during this timeYou are not covered during this time

Your CostsYour Costs PremiumPremium – The amount the policy-holder pays to the health plan – The amount the policy-holder pays to the health plan

each month to purchase health coverage each month to purchase health coverage

DeductibleDeductible -The amount that the policy-holder must pay out-of- -The amount that the policy-holder must pay out-of-pocket before the health plan pays its share pocket before the health plan pays its share

Deductible could be yearly or could be per injury / illnessDeductible could be yearly or could be per injury / illness Example: Example:

• Your yearly deductible - $500.00Your yearly deductible - $500.00• Your medical Bill – $2,500.00Your medical Bill – $2,500.00

Insurance company pays $2,000.00Insurance company pays $2,000.00 You pay $500.00You pay $500.00

CopaymentCopayment The amount that the policy-holder must pay out of The amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service. 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 For example, a policy-holder might pay a $45 copayment for a doctor's visit, or to obtain a prescription. visit, or to obtain a prescription.

A copayment must be paid each time a particular service is obtainedA copayment must be paid each time a particular service is obtained

Example of what a plan would Example of what a plan would look like…look like…

http://www.tffhp.org/summary_plahttp://www.tffhp.org/summary_plan_description.htmn_description.htm

Managed CareManaged Care- Organized system of health care services Organized system of health care services

designed to control health care costsdesigned to control health care costs

- One of the most characteristic forms of managed One of the most characteristic forms of managed care is the use of a panel or network of health care is the use of a panel or network of health care providers to provide care to enrollees care providers to provide care to enrollees

- Managed care usually involves:Managed care usually involves:- Standards for selecting providersStandards for selecting providers- An emphasis on preventive care An emphasis on preventive care - Financial incentives to encourage enrollees to use Financial incentives to encourage enrollees to use

care efficientlycare efficiently

Two main kinds of Managed Care Two main kinds of Managed Care InsuranceInsurance

HMO – Health Maintenance OrganizationHMO – Health Maintenance Organization PPO – Preferred Provider OrganizationPPO – Preferred Provider Organization

HMOHMO

HMOs manage their patients' health care by HMOs manage their patients' health care by reducing unnecessary servicesreducing unnecessary services

To achieve this, most HMOs require members to To achieve this, most HMOs require members to select a primary care physician (PCP)select a primary care physician (PCP) This physician acts a a gatekeeper to medical This physician acts a a gatekeeper to medical

servicesservices most medical needs must first go through the PCP, most medical needs must first go through the PCP,

who authorizes referrals to specialists or other doctors who authorizes referrals to specialists or other doctors if deemed necessary if deemed necessary

• This is called a “referral”This is called a “referral” Emergency medical care does not require prior Emergency medical care does not require prior

authorization from a PCP authorization from a PCP

HMO’s and non-networkHMO’s and non-network

Most HMO’s will only pay for medical bills Most HMO’s will only pay for medical bills for you PCP of for services your PCP for you PCP of for services your PCP approves through referralapproves through referral

HMOs typically provide no coverage for HMOs typically provide no coverage for care received from non-network care received from non-network physicians (with exceptions for emergency physicians (with exceptions for emergency care while traveling, etc.). care while traveling, etc.).

HMO Public ImageHMO Public Image

HMOs often have a negative public image HMOs often have a negative public image due to their restrictive appearance. due to their restrictive appearance.

HMOs have been the target of lawsuits HMOs have been the target of lawsuits claiming that the restrictions of the HMO claiming that the restrictions of the HMO prevented necessary careprevented necessary care

Usually a “cheaper” planUsually a “cheaper” plan

PPO – Preferred Provider PPO – Preferred Provider OrganizationOrganization

Organization of medical doctors, hospitals Organization of medical doctors, hospitals and other health care providersand other health care providers ““network” or “preferred provider”network” or “preferred provider”

Network is contracted with an insurer to Network is contracted with an insurer to provide health care coverage at a reduced provide health care coverage at a reduced rate (substantial discount)rate (substantial discount)

Some surgeries or procedures may need Some surgeries or procedures may need to require pre-approval by the insurance to require pre-approval by the insurance companycompany

PPO’s and non-networkPPO’s and non-network

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

PPO Public ImagePPO Public Image

Usually allow more freedom than HMOUsually allow more freedom than HMO

Usually a more expensive type of insurance planUsually a more expensive type of insurance plan

Networks can changeNetworks can change

If you choose to get medical care from a If you choose to get medical care from a provider who is out of network….It costs you provider who is out of network….It costs you more moneymore money

Federal Programs for Health Federal Programs for Health CoverageCoverage

Medicaid – health insurance for people Medicaid – health insurance for people with lower incomes with lower incomes Funded by state and federal governmentFunded by state and federal government Eligibility rule vary state to stateEligibility rule vary state to state

• Example of Medicaid requirementsExample of Medicaid requirements You're a pregnant woman who meets income You're a pregnant woman who meets income

requirements. For example, a family of four making requirements. For example, a family of four making $23,225 a year or less qualifies.$23,225 a year or less qualifies.

Your family's assets are less than $2,000 Your family's assets are less than $2,000

Federal Programs for Health Federal Programs for Health CoverageCoverage

Medicare –Government health coverage Medicare –Government health coverage for people 65 years or olderfor people 65 years or older

***In many cases Medicare pays a portion ***In many cases Medicare pays a portion of the person’s health care cost. The rest of the person’s health care cost. The rest is paid by the persons Medicaid or is paid by the persons Medicaid or supplemental insurance plansupplemental insurance plan

WICWIC

Women Infants and ChildrenWomen Infants and Children Program that helps mothers and children Program that helps mothers and children

with medical billswith medical bills Prenatal carePrenatal care Preventive screeningsPreventive screenings ImmunizationsImmunizations Pay for “proper” food and medicinesPay for “proper” food and medicines

Single Payer SystemSingle Payer System National Health CareNational Health Care Centrally controlled heath care system Centrally controlled heath care system

(government)(government) TaxesTaxes

Sometime requires supplemental health Sometime requires supplemental health insuranceinsurance

U.S. ranks U.S. ranks 22nd in infant mortality 22nd in infant mortality 46th in life expectancy46th in life expectancy 37th in health system performance, between Costa 37th in health system performance, between Costa

Rica and Slovenia Rica and Slovenia

Bad system or Broken System?Bad system or Broken System?

In a 2007 comparison by the In a 2007 comparison by the Commonwealth FundCommonwealth Fund of health care in the U.S. of health care in the U.S. with that of Germany, Britain, Australia, New with that of Germany, Britain, Australia, New Zealand, and Canada, the U.S. ranked last on Zealand, and Canada, the U.S. ranked last on measures of quality, access, efficiency, equity, measures of quality, access, efficiency, equity, and outcomesand outcomes

30 percent of U.S. health care dollars, or more 30 percent of U.S. health care dollars, or more than $1,000 per person per year, went to health than $1,000 per person per year, went to health care administrative costs care administrative costs

Federal Programs for Health Federal Programs for Health CoverageCoverage

COBRA COBRA Consolidated Omnibus Budget Reconciliation Consolidated Omnibus Budget Reconciliation

Act (1985)Act (1985) If you lose your job you may continue to pay If you lose your job you may continue to pay

your insurance premium and maintain your insurance premium and maintain coverage for up to 18 monthscoverage for up to 18 months

This also applies to children on insured This also applies to children on insured employeesemployees• If a child somehow looses full-time student status If a child somehow looses full-time student status

that child may make a COBR payment to maintain that child may make a COBR payment to maintain coveragecoverage

CoinsuranceCoinsurance Instead of paying a fixed amount Instead of paying a fixed amount up front (a copayment), the policy-holder must up front (a copayment), the policy-holder must pay a percentage of the total cost.pay a percentage of the total cost. For example, the member might have to pay 20% of For example, the member might have to pay 20% of

the cost of a surgery, while the health plan pays the the cost of a surgery, while the health plan pays the other 80%. Because there is no upper limit on other 80%. Because there is no upper limit on coinsurance, the policy-holder can end up owing very coinsurance, the policy-holder can end up owing very little, or a significant amount, depending on the actual little, or a significant amount, depending on the actual costs of the services they obtain.costs of the services they obtain.

SickoSicko

http://www.youtube.com/watch?v=http://www.youtube.com/watch?v=xlDAUKSh9CQxlDAUKSh9CQ