Objectives:
-TSWBAT differentiate between types of insurance
programs and terms by taking notes.
-TSWBAT understand the different types of insurance by
analyzing which health insurance plan available would
best fit the students’ needs.
• A person buys insurance and the
insurance provider agrees to pay or
reimburse for the costs of medical
care
• “Gambling analogy”
• In 2006, 47 million people in the U.S. (16% of the
population) who were without health insurance for at least
part of that year
https://www.youtube.com/watch?v=dTuIr_zrHkQ
Can name some
carriers/companies???
http://www.healthinsurancesort.com/carrier-list.htm
• What’s the #1 reason young adults end
up in bankruptcy?
• Large, unexpected medical bills from
• an accident
• an illness
Combined with…
• NO health insurance
• YES!
• How much does a broken leg cost?
• $5,000 - $20,000
• How much does a serious car accident cost?
• $50,000
Group Policies –
• provided by employer
• you employer pays for all
or most of you insurance
plans cost
• All employees at work
have the same health
insurance options as you
do
• Commonly called
“benefits”
Individual Policies –
• you buy the policy
yourself
• Very similar to the way you
get car insurance
• About 9% of the
population gets their
health insurance this way
• Provider –
• provides a health care service
• Network –
• group of hospitals and/or doctors that jointly
provide care to a given group of patients
covered by health insurance
• 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
• Covered Expense –
•something that the insurance plan will
pay for
• Exclusions –
•Not all services are covered. The policyholder is generally expected to pay the
full cost of non-covered services out of
their own pocket.
• Premium –
• The amount the policy-holder pays to the health plan
each month to purchase health coverage
• Deductible –
• The amount that the policy-holder must pay out-ofpocket before the health plan pays its share
• Deductible could be yearly or could be per injury /
illness
• Read italic paragraph in notes…
• Example: Your yearly deductible is $500.00 and your medical Bill is
$2,500.00. Your Insurance company pays $2,000.00 and you pay the
deductible of $500.00.
• Copayment
–The amount that the policy-holder must pay out of
pocket before the health plan pays for a particular
visit or service.
–Example • a policy-holder might pay a $45 copayment for a
doctor's visit, or to obtain a prescription.
–A copayment must be paid each time a particular
service is obtained
–Read italic paragraph in notes…
-
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
-
Managed care usually involves:
1. Standards for selecting providers
2. An emphasis on preventive care
3. Financial incentives to encourage enrollees to use care
efficiently
• HMO – Health Maintenance Organization
• PPO – Preferred Provider Organization
• Co-Insurance
• Other kinds of plans (we will not go in depth with these plans):
• EPO = Exclusive Provider Organization
• POS = Point of Service Plan
• HDHP = High Deductible Health Plan
• Catastrophic Health Insurance Plan
• HMO = Health
Maintenance
Organization
• Manage patients' health
care by reducing
unnecessary services
• Most HMOs require members to select a
primary care physician (PCP)
•Physician acts a gatekeeper to medical
services
• PCP authorizes referrals to specialists or other
doctors if deemed necessary. This is called a
“referral.”
• Emergency medical care does not require
prior authorization from a PCP
• Most HMO’s will only pay for medical bills for
services your PCP approves through referral
• HMOs typically provide no coverage for care
received from non-network physicians
• exceptions for emergency care while
traveling, etc.
• 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 pre-approval
by the insurance company
• PPO’s will reimburse some of your costs if you go out of
network:
• PPO may reimburse 90% of costs for care received within the network,
but only 70% of costs for non-network care
CAN YOU NAME THREE DIFFERENCES BETWEEN A PPO AND A
HMO?
• Instead of paying a fixed amount up front (a
copayment), the policy-holder must pay a percentage
of the total cost.
• Because there is no upper limit on coinsurance, the
policy-holder can end up owing very little, or a
significant amount, depending on the actual costs of
the services they obtain.
– Example• member might have to pay 20% of the cost of a surgery, while the
health plan pays the other 80%.
• 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
• Medicaid –
• health insurance for people with lower incomes
• Funded by state and federal government
• Eligibility rule vary state to state
• Example of Medicaid requirements
• You're a pregnant woman who meets income
requirements. For example, a family of four making
$23,225 a year or less qualifies.
• Your family's assets are less than $2,000
• 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
• Women Infants and Children
• Program that helps mothers and children with medical bills
•
•
•
•
Prenatal care
Preventive screenings
Immunizations
Pay for “proper” food and medicines
You do not need to copy this acronym onto your t-chart…
• Children’s Health Insurance Program
• 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.
You do not need to copy this acronym onto your t-chart…
• COBRA
• Consolidated Omnibus Budget Reconciliation Act (1985)
• Lose your job - may continue to pay your insurance premium & maintain
coverage
• This also applies to children on insured employees
• If a child somehow loses full-time student status that child may make a
COBRA payment to maintain coverage
You do not need to copy this acronym onto your t-chart…
• Beginning Oct 1 2013, the Health Insurance Marketplace will
make it easy for Pennsylvanians to:
• compare qualified health plans
• get answers to questions
• find out if they are eligible for lower costs for private insurance or health
programs like Medicaid and the Children’s Health Insurance Program
(CHIP), and enroll in health coverage.
• Uninsured Pennsylvanians who are eligible for coverage through the
Marketplace.
•
•
•
•
•
•
•
•
1,242,350 (12%) are uninsured and eligible
928,243 (75%) have a full-time worker in the family
491,258 (40%) are 19-34 years old
864,180 (70%) are White
201,028 (16%) are African American
114,374 (9%) are Latino/Hispanic
33,494 (3%) are Asian American or Pacific Islander
707,872 (57%) are male
• 1,141,720 (92%) of Pennsylvania’s uninsured and eligible population
may qualify for either tax credits to purchase coverage in the
Marketplace or for Medicaid if Pennsylvania takes advantage of the
new opportunity to expand Medicaid coverage under the Affordable
Care Act.
• Pennsylvania has received $34,832,212 in grants for research,
planning, information technology development, and implementation
of its Health Insurance Marketplace.
Let’s see some plans available on
www.healthcare.gov!
• Single Payer =
• Single-payer health care is a system in which the government, rather than
private insurers, pays for all health care costs
• Universal Health Care =
• It is organized around providing a specified package of benefits to all members
of a society with the end goal of providing financial risk protection, improved
access to health services, and improved health outcomes. Universal health care is
not a one-size-fits-all concept
Centrally controlled heath care system (government) – pay higher taxes
Sometime requires supplemental health insurance
http://chartsbin.com/view/z1a
Please write your answer on your
notes outline. Be prepared to share
your thoughts shortly…
Do you know what coverage you will have when you graduate from NP?
• On the post-it note, please write a response to one of the following:
– A question you have about today’s notes
– A reaction about health insurance in the USA or to your health insurance policy
– Something you learned that was new regarding health insurance
DO NOT WRITE YOUR NAME ON THE NOTE
DO WRITE YOUR CLASS PERIOD/LETTER DAY
PLEASE BE HONEST AND RESPECTFUL WITH YOUR RESPONSE