Name: _____________________________________ Class Pd./Letter Day: _______________
Health Insurance Notes Outline
What is Health Insurance?
A person buys insurance and the insurance provider agrees to pay or reimburse for the costs of
________________________________.
Group VS. Individual Policy
Group Policy
Individual Policy
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Policy Terms of Health Insurance
Provider – who provides a _________________________________________________.
Network - A group of hospitals and/or doctors that ________________ provide care to a given group
of patients covered by health insurance.
Major Medical - A form of medical insurance designed to ___________ a basic medical expense plan
in the event of extraordinary medical expenses (example: extreme illness or disability).
Covered Expenses - A covered expense is something that the health insurance company will pay for.
Exclusions - Not all services are covered. The policy-holder is generally expected to pay the
___________ cost of non-covered services out of their _______________ _________________.
The Costs of Health Insurance:
Premium - The amount the policy-holder pays to the health plan each month to purchase __________.
Deductible- The amount that the policy-holder must pay __________________ before the health plan
pays its share. Deductible could be _______________ or could be per _________________________.
WHAT THE EXPERTS SAY…The specific amount of claims you will pay before the company
pays. The higher you deductable, the lower your premium can be.
Co-Payment - The amount that the policy-holder must pay _______________ before the health plan
pays for a particular visit or service. A co-pay is paid each time for the visit or service.
WHAT THE EXPERTS SAY…A co- payment is certain amount that you pay for medical costs.
For example, you pay $5 every time you have a prescription filled.
Managed Care Health Care System:
A managed care system is an organized system of health care services designed to control health care
costs. A managed care system uses a panel or network of health care providers to provide care to
enrollees
Usually Involves:
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HMO ( ________________ _______________________ ______________________)
HMOs manage their patients' health care by _____________________ unnecessary services.
To achieve this, most HMOs require members to select a _____________ __________ _________
(PCP).
 This physician acts a _________________ 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 “__________________”.
 Emergency medical care does not require prior authorization from a PCP
HMO and Non-Network:
- Most HMO’s 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.).
WHAT THE EXPERTS SAY…HMOs offer coverage similar to that of a major medical policy.
These policies have co-payment obligations for you for the various covered benefits. This is a
managed care plan where you choose your primary care physician (PCP) from a list of network
providers. Your PCP is typically responsible for the management of most aspects relating to
your healthcare. HMOs require that an in-network doctor provide care in order to have your
claim paid by the HMO (with the exception of emergency care). Be sure to read the policy
related to emergency room care coverage. Many HMOs require referrals and preauthorizations for any care other than a PCP visit. Be sure you understand your contract and
your obligations for getting referrals and pre-certifications before you receive treatment. These
policies will also have exclusions and non-covered services in the same way as a major medical
policy. Make sure you understand the limitations on your policy.
PPO ( ____________________
____________________
_________________)
Organization of medical doctors, hospitals and other health care providers called “______________” or
“preferred providers.”
Network is ___________________ with an insurer to provide health care coverage at a
______________ rate (substantial discount).
Some surgeries or procedures may need to require ____________________ by the insurance company
PPO and Non Network:
PPO may reimburse _________ percent of costs for care received within the network, but only
_________ percent of costs for non-network care
WHAT THE EXPERTS SAY…PPOs provide consumers with economic incentives if they contract to
patronize a particular group of healthcare providers. There are many types and styles of PPOs.
One common style of PPO may pay 80/20 if you go to a doctor that is in the network of providers.
The PPO will pay 80% of your bill; you pay 20% after any applicable deductibles. If you go out of
network, the amount a PPO pays will change (usually less).
Inside this box – can you tell me three differences between a PPO vs. a HMO?
1.
2.
3.
Co-Insurance:
Instead of paying a fixed amount up front (a copayment), the policy-holder must pay ______________
of the total cost.
Because there is no upper limit on co-insurance, the policy-holder can end up owing
____________________, or a _________________________________, depending on the actual costs
of the services they obtain.
Other Types of Insurance Plans and Add-On’s to Insurance:
Dental Insurance:
Vision Insurance:
Hospitalization Insurance:
Surgical Insurance:
Disability Insurance:
___________________________________________________________________________________
Government Programs
Medicaid – www.medicaid.gov
 Health insurance for people ______________________________________________________
 Funded by ___________________ and _________________________ government
 Eligibility rule vary state to state…
Medicare – www.medicare.gov
 Government health coverage for people _______________________________________
 In many cases Medicare pays a portion of the person’s health care cost.
 The rest is paid by the _______________ or ___________________________ insurance plan
WIC – www.fns.usda.gov/wic
 W_________________ I___________________ and C_________________________
 Program that helps mothers and children with medical bills:
o Prenatal care
o Pay for “proper” food and
o Preventive screenings
medicines
o Immunizations
CHIP – http://www.chipcoverspakids.com/
 C_________________ H___________________ I __________________ P______________
 Uninsured Pennsylvania children and teens that are not eligible for Medicaid have access to
affordable, comprehensive health-care coverage.
 Once enrolled, children are guaranteed 12 months of CHIP coverage unless they no longer meet
the basic eligibility requirements.
 Families must renew their coverage every year in order for the coverage to continue.
 There is no waiting list to enroll in CHIP.
COBRA - http://cobrahealthinsurance.com/Cobra_Health_Insurance_Summary.html
 C___________________ O_______________ B__________________ R_________________
A________ (1985)
 Lose your job - may continue to pay your insurance premium & maintain coverage
 This also applies to children on insured employees
USA vs. The World – What Are Other Countries Doing?
National Health Care / Universal Health Care
 Centrally controlled heath care system (government) – they pay __________________________
 Sometime requires supplemental health insurance
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YOUR RESPONSE: What are your thoughts about our system? Can we fix our system?