Medical Insurance A Tale by Mrs. Tesora

Senior Medical Assisting Class

Class of 2017

Sharing a Language

Little Miss Muffet

Sat on a tuffet,

Eating her curds and whey;

Along came a spider,

Who sat down beside her,

And frightened Miss Muffet

away.

Sharing a Language

Little Miss Muffet

Sat on a tuffet, (foot stool)

Eating her curds and

whey; (cottage cheese)

Along came a spider,

Who sat down beside her,

And frightened Miss Muffet

away.

Sharing Words & Meaning •Beneficiary – The person that benefits from having insurance.

•Policy Holder – The person that signed up for and pays for the

medical insurance policy or “holds” the policy (plan).

•Guarantor – The person that will pay or guarantee to pay

any outstanding money owed after the medical insurance has paid

their part.

•Premium – The amount of money or cost paid to an insurance

company before (pre-) they are “covered” by medical insurance.

•Medical Insurance – An agreement with a policy holder who

pays a premium to ensure the insurance company will honor or pay

for certain medical costs as outlined in the written agreement or

plan.

Sharing Words & Meaning •Copayment – The amount of money that the

person receiving care or the guarantor pays at the

time care is provided.

•Explanation of Benefits EOB – A written document that

outlines the medical bill:

Fees/costs of medical care rendered or delivered by

hospitals, medical providers and testing facilities at the

point/place of care – poc.

The EOB also explains the fees paid by the insurance

company and the guarantor pays (copayments,

deductibles).

Sharing Words & Meaning •Preauthorization – Before (pre-) services can

be rendered some services outlined in the plan will

require the insurance company to authorize

(agree) to pay for out of medical need (necessity).

•Referral – When a provider recommends or

refers someone for services needed. This is a formal

request to the insurance company for

preauthorization.

•Deductible – An amount of money that the

patient has to pay for medical services before the

medical insurance plan begins to pay.

Purpose Why is the Medical Insurance important?

The purpose of Medical Insurance is to help a

person afford the cost of medical care.

What is the number one reason families

in America go Bankrupt?

Chronic, Acute or Catastrophic Illness.

Think about: Are there any hidden costs of

serious illness that insurance does not cover?

Purpose Why is the main Medical Insurance

important?

“When you are sick, the last thing you want to worry

about is if you can access the care you need.”

What is the number one reason families

in America go Bankrupt?

“Americans that have a sick person in their family

are very likely to experience poverty.”

Purpose Hidden / Not covered Costs:

•Lost income – Can you work?

•Copayment/Deductibles/Premiums – How

much does that cost?

•Over the counter (OTC) medicine, Durable

Medical Equipment (DMEs) not covered.

Think about it: What is the advantages of Home

care vs. Tertiary Care (Long Term Nursing Home) for

the elderly and disabled?

Types of Coverage / Plans Traditional Insurance (e.g. Blue Cross / Blue Shield) Fee for Service

Managed Care (HMO, POS, PPO)

•Pays fees per contracted agreements

•Health Maintenance Organization (HMO)

•Exclusive to a network of providers

•Point of Service (POS)

•Freedom to go outside network

•Preferred Provider Organization (PPO)

•Insurance company has an agreement

for a discounted rate in network

Understanding the Types of Coverage Medicaid – (MassHealth Standard) The

disabled and poor people are eligible.

Medicare – Seniors (over 65) and permanently

disabled people are eligible.

Explanation of Benefits (EOB) Explanation of Benefits

Patient: Jack

Diagnosis: Broken Crown

Health Care Service Fee Insurance Payment

ER Visit $400 $300

CT Scan $8,000 $7,500

Suturing $170 $170

Total $8,570 $7970

Balance Due $600

Co-pay -$100

Deductible not met $500 What does

Jack owe?

Medicaid Humpty Dumpty sat on a wall.

Humpty Dumpty had a great fall.

All the kings horses and all the kings men couldn’t put Humpty together again.

Humpty now lives with a chronic debilitating condition – Broken Egg Syndrome – and is now disabled.

What medical insurance would cover him?

State Medicaid/

MassHealth Standard

Or

Medicare if Brown Egg

Syndrome permanently

prevents Humpty from

working.

Medicaid / MassHealth Standard

There was an old woman who lived in a shoe.

She had so many children, she didn't know what to do.

She gave them some broth without any bread;

And whipped them all soundly and put them to bed.

The Children's Health

Insurance Program (CHIP)

provides low-cost health

coverage to children in families

that earn too much money to

qualify for Medicaid.

Definition of Poverty 2016 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND

THE DISTRICT OF COLUMBIA

PERSONS IN

FAMILY/HOUSEHOLD POVERTY GUIDELINE

For families/households with more than 8 persons, add $4,160 for each

additional person.

1 $11,880

2 16,020

3 20,160

4 24,300

5 28,440

6 32,580

7 36,730

8 40,890

Understanding the Types of Coverage Traditional Insurance –

Remember Jack & Jill have Blue Cross / Blue Shield

Medicaid –

Think Humpty Dumpty / Disabled People with

limited income. The Woman that Lived in a Shoe

/ Poor People that have no money or that are

living in poverty (400% below the poverty line

for MassHealth)

Medicare –

Remember Rip Van Winkle – Old Man

Medicare

Rip Van Winkle went

for a hike to get away

from his nagging wife

Unable to handle the

pressures of having a

job, he drank some

moonshine and fell

asleep on a log.

To his surprise when

he awoke…

Medicare

He had aged

many years!

As an old many he had

many fears.

How will Rip pay for

his medical bills?

Medicare

He had aged

many years!

As an old man he had

many fears.

How will Rip pay for

his medical bills?

MEDICARE?

Medicare

Medicare A – Hospital ($$$$)

Medicare B – Outpatient ($$$)

Medicare C - Consumer /

Commercial

(Examples: Medicare Advantage,

Senior Care Options)

Medicare D – Remember Donut

Hole and Prescriptions

Medicare

Is he really eligible?

Did he worked long enough and

paid into Medicare through his

employment taxes?

If he did not work long enough or had a

disabling condition that prevented him

from working, what insurance would

cover him other than Medicare?

Advanced Learning Credit

1. Tell me about armed forces and their families Medical Care?

2. Describe a Provider Network (e.g. Partners)

3. Process map the “Referral Process”.

4. Demonstrate and understanding in your preferred method (outline, charts/graphs, poster, oral presentation) of Worker’s Compensation.

5. Identify a type of organization or a business that is “self-insured”.

Explore a Career in Healthcare Billing American Academy of Professional Coders

(AAPC) at http://aapc.com

American Health Information Management (AHIMA) at http://www.ahima.org

American Medical Billing Association (AMBA) at http://www.ambanet.net

National Association of Claims Assistance Professional (NACAP) at https://www.medical-codingbilling.com

National Electronic Billers Alliance (NEBA) at http://www.nebazone.com/part1.html