Health Insurance
Consumer Health Unit
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.
Health Insurance
• 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
Why do I need health insurance?
https://www.youtube.com/watch?v=dTuIr_zrHkQ
Can name some
carriers/companies???
http://www.healthinsurancesort.com
/carrier-list.htm
Introduction
• 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
Do you really need it?
• YES!
• How much does a broken leg cost?
– $5,000 - $20,000
• How much does a serious car accident cost?
– $50,000
Group vs. Individual Insurance
Group Policies –
• provided by employer
Individual Policies –
• you buy the policy
yourself
– 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”
– Very similar to the way
you get car insurance
• About 9% of the
population gets their
health insurance this
way
Health Insurance Terms
• 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
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
– John Q movie??!!
Insurance Terms Continued
• Covered Expense –
– something that the insurance plan will pay for
• Exclusions –
– Not all services are covered. The policy-holder is
generally expected to pay the full cost of noncovered services out of their own pocket.
Your Costs
• 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-of-pocket
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
deductable of $500.00.
Costs!!
• 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…
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
-
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
Kinds of Managed Care Insurance
• HMO – Health Maintenance Organization
• PPO – Preferred Provider Organization
• Co-Insurance
• Other kinds of plans (discussed in the ACA – 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
• HMO = Health
Maintenance
Organization
• Manage patients' health
care by reducing
unnecessary services
HMO
• 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
HMO’s vs. non-network
• 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.
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 pre-approval by the insurance company
PPO’s vs. non-network
• 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 nonnetwork care
CAN YOU NAME THREE DIFFERENCES
BETWEEN A PPO AND A HMO?
Do you know what type of insurance
plan you have? Do you know its
restrictions?
Co-Insurance
• 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%.
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 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
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 – Government Program
• 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 tchart…
CHIP
• 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…
Federal Programs for Health Coverage
• 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…
Pennsylvania Health Care
• 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.
PA Health Care (con’t)
• 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
PA Health Care (con’t)
• 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.
Healthcare Marketplace
Let’s see some plans available on
www.healthcare.gov!
What else is out there?
• 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
World Map
http://chartsbin.com/view/z1a
What are your thoughts about our
system? Can we fix our system?
Please write your answer on your
notes outline. Be prepared to share
your thoughts shortly…
Health Insurance
After High School
Do you know what coverage you will have when
you graduate from NP?
Exit Ticket
• 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