Health Insurance
Consumer Health Unit
Objectives:
-TSWBAT differentiate between types of insurance
programs and terms.
-TSWBAT analyze which health insurance plan
available would best fit the students’ needs.
Health Insurance Basics
A
contract between you and
your insurance company
 You buy a plan, and the
company agrees to pay part
of your medical costs when
you get sick or hurt
 Protects you from high,
unexpected costs
How Health Insurance Works
– fixed amount you pay to your
insurance plan, usually every month (even
if you don’t use medical care that month)
 Deductible – the amount you pay for care
before the insurance company starts to
pay its share
 Copayment – fixed amount you’ll pay for
a medical service after you’ve met your
deductible
 Coinsurance – it’s a percentage of costs
you pay
 Premium
Group vs. Individual Insurance

Group Policies –
provided by employer


Your employer pays
for all or most of your
insurance plans cost
All employees at work
have the same health
insurance options as
you do (may have
some choices)
 Commonly called
“benefits”

Individual Policies –
you buy the policy
yourself

Very similar to the way
you get car insurance
Health Insurance Terms
– provides a health care service
Example: dermatologist, orthopedic
 Network – group of hospitals and/or
doctors that jointly provide care to a given
group of patients covered by health
insurance
 Provider
Health Insurance Terms
 Major
Medical - form of medical insurance
designed to supplement a basic medical
expense plan in the event of extraordinary
medical expenses
 Example - extreme illness or disability
Health Insurance Terms
Expense – something that the
insurance plan will pay for
 Covered
–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.
 Exclusions
Health Insurance Terms
 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
Health Insurance Terms
 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!!!
Managed Care
 Organized
system of health care services
designed to control health care costs
 Use of a panel or network of health care
providers to provide care to enrollees
 Holds down costs by limiting patients’
choices (standards for selecting providers)
and encourages preventive care
Two main kinds of Managed Care
Insurance
– Health Maintenance Organization
 PPO – Preferred Provider Organization
 HMO
HMO – Health Maintenance Organization

Manage patients' health care by reducing unnecessary
services
 Lower premiums and/or copayments
 Most HMOs require members to select a primary care
physician (PCP)
 PCP = physician acts as a gatekeeper to medical
services
 PCP authorizes referrals to specialists or other
doctors if deemed necessary.
 Emergency medical care does not require prior
authorization from a PCP
 Typically provide no coverage for care out of network
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 preapproval by the insurance company
 May reimburse some of your costs if you go out of
network
 More flexibility, network is large, higher premiums
Other Types of Medical Insurance / “Add On’s”
•
Dental Insurance – required to have if age 18 or younger /
helps totally or partially cover dental cleanings and other
procedures needed (fillings, root canals, crowns, etc.)
•
Vision Insurance – not required to have / helps partially
cover eye check-ups, contacts or glasses
•
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
Federal Programs for Health
Coverage
 Medicaid



–
Health insurance for people with lower
incomes
Funded by state and federal government
Eligibility rule varies state to state
• Example of Medicaid requirements


A family of four making $23,225 a year or less qualifies.
Your family's assets are less than $2,000
Federal Programs for Health
Coverage
 Medicare



–
Government health coverage for people 65
years or older
In many cases Medicare pays a portion of the
person’s health care cost.
The rest is paid by the person or
supplemental insurance plan.
WIC – Women, Infants & Children
 Government
program that helps mothers
and children with medical bills
 Examples: prenatal care, immunizations,
medication
CHIP – Children’s Health
Insurance Program (PA)
 Children
and teens that are not eligible for
Medicaid have access to affordable,
comprehensive health care coverage
 Once enrolled, 12 months of CHIP is
guaranteed unless they no longer meet
the requirements
 Families must renew their coverage each
year in order for coverage to continue
COBRA – Consolidated
Omnibus Budget Reconciliation
Act
 Developed
in 1985
 If you lose your job, you may continue to
pay your insurance premium and maintain
your health coverage
 Also applies to children that loses full-time
student status
Obama Care
 Health
care plan for America
 President Obama signed the Affordable
Care Act in March of 2010
 The law puts in place comprehensive
health insurance reforms for four years
and beyond (for example, by 2014 all
Americans will have access to affordable
health insurance options)
 The political issues behind this law caused
the government to shut down in 2013
Affordable Care Act
Coverage:
 Ends pre-existing condition exclusions for children
(plans can no longer limit or deny benefits to
children under 19 due to pre-existing condition)
 Keeps young adults covered (if you are under 26,
you may be eligible to remain on your parent’s plan)
 Ends arbitrary withdrawals of insurance coverage
(no cancellations because of a honest mistake)
 Guarantees your right to appeal (you have the right
to ask that your plan reconsider its denial of
payment)
Affordable Care Act
Care:
 Covers preventive care at no cost to you
 Protects your choice of doctors (choose
the PCP from your plan’s network)
 Removes insurance company barriers to
emergency services (you can seek
emergency care at a hospital outside of
your health plan’s network)
Affordable Care Act

The health insurance marketplace helps
uninsured people find health coverage
 If you don’t have coverage in 2015, you will pay
a penalty higher of these two amounts: 2% of
your yearly household income or $325 per
person for the year ($162.50 per child under 18)
 Open enrollment ends February 15, 2015
 You are considered covered if you have
Medicare, Medicaid, CHIP, job-based plan,
COBRA, plan you bought yourself, retiree
coverage, etc.
A look at Obamacare in 2015
 Since
this year’s sign up period began on
November 15, almost 10 million people
have enrolled in private health insurance
plans via the exchanges (by February)
 There is currently a special enrollment
period for those who were tardy and did
not realize they would pay a fine (some
states are not doing a grace period) until
they were filing their taxes