Health InsuranceConsumer 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– 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

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 non-covered 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 providers2. 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 non-network care

Do you know what type of insurance plan you have? Do you know its

restrictions?

CAN YOU NAME THREE DIFFERENCES BETWEEN A PPO AND A HMO?

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 t-chart…

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 NOTEDO WRITE YOUR CLASS PERIOD/LETTER DAY

PLEASE BE HONEST AND RESPECTFUL WITH YOUR RESPONSE