1. Health Care Concepts krishnatrainingusa@gmail.com Presenter: Krishi

2. Health Care Concepts- Day1  Health Care Overview What is Health Insurance? Types of Health Insurance or Health Coverage Types of Health Insurance Plans Private Insurance Overview Public Insurance Overview HealthCare Terminology

3. Health Care Concepts-  Healthcare Components Provider Subsystem Recipient Subsystem Claims Subsystem Managed Care Referral Subsystem

4. What is Health Insurance? Health insurance is a type of insurance coverage that covers the cost of an insured individual's medical and surgical expenses. Depending on the type of health insurance coverage, either the insured pays costs out-of-pocket and is then reimbursed, or the insurer makes payments directly to the provider. In health insurance terminology, the "provider" is a clinic, hospital, doctor, laboratory, health care practitioner, or pharmacy. The "insured" is the owner of the health insurance policy; the person with the health insurance coverage.

5. Is Health Insurance coverage a right or a product?  In countries, such as the USA, health insurance coverage is seen somewhat differently - with the exception of some groups, such as elderly and/or disabled people, veterans and some others, it is the individual's responsibility to be insured.  Everybody at some time in their life, and often on many occasions, will need some kind of medical attention and treatment. When medical care is required, ideally the patient should be able to concentrate on getting better, rather than wondering whether he/she has got the resources to pay for all the bills.

6. Types of Health Insurance Broadly speaking there are two types of health insurance: 1. Private Health Insurance 2. Public Health Insurance

7. Types of Health Insurance 1) Private health insurance - the CDC (Centers for Disease Control and Prevention) says that the US health care system is heavily reliant on private health insurance. 58% of Americans have some kind of private health insurance coverage. Examples of Private Insurance:Anthem,Aetna,BCBS

9. Types of Health Insurance 2) Public (government) health insurance - for this type to be called insurance, premiums need to be collected, even though the coverage is provided by the state. Examples of public health insurance in the USA is Medicare, which is a national federal social insurance program for people aged 65+ years as well as disabled people, and Medicaid which is funded jointly by the federal government and individual states (and run by individual states), SCHIP which is aimed at children and families who cannot afford private insurance, but to not qualify for Medicaid. Other public health insurance programs in the USA include TRICARE, the Veterans Health Administration, and the Indian Health Service

10. Types of Health Insurance Plans The following are types of health insurance plans in the USA 1.Managed care plans 2.Indemnity Plans 3.Health Maintenance Organizations (HMO) 4.Preferred Provider Organization (PPO) 5.Point-of-Service Plans (POS) 6.Health Savings Accounts (HSA)

11. Types of Health Insurance Plans Managed care plans are health insurance plans that have a contract with health care providers and medical facilities to provide medical care at special prices (lower costs). These providers form the plan's network. The network will have rules, which stipulate how much of the care the plan will pay for. Indemnity Plans: The insured can choose any doctor he/she wants. The doctor, hospital or the insured submits a claim for reimbursement to the health insurance company. It is important to remember that, like any insurance plan, the insured will only be reimbursed according to what is listed and mentioned in the Benefit Summary. It is important to read the Summary carefully and understand all that is printed, even the "small print". Most indemnity plans claim to cover "the vast majority of procedures".

12. Types of Health Insurance Plans Coinsurance - while indemnity plans do not pay for all of the medical and surgical services, they typically pay for at least 80% of the customary and usual costs, while the insured is liable for the remaining 20 or so percent. The insured is also liable for any excess charges, e.g. if the provider charges more than what is considered as a reasonable and customary fee. Look at the example below: Example of Coinsurance and excess charges You see a doctor for "diabetes care" The insurer deems that the customary fee for this type of diabetes care is $200. The insurance company pays $160 (80%), while the insured (you) is expected to pay for the rest ($40). However, if the provider bills you for $250, you will have to pay for those extra $50. So, you will have to pay $40 + $50 = $90. The 8/20 level coinsurance ratio is only a typical example given in this article. Some plans may be 75/25 or 70/30.

13. Types of Health Insurance Plans Deductibles - the amount of covered expenses the insured has to pay before the reimbursement system kicks in and starts covering medical costs. The deductible total may range from $100 to $300 per person annually, or from $500 to $1,000 annually for a whole family. Out-of-pocket maximum - as soon as the insured's covered expenses reach a certain amount during a 12-month period, the plan will cover all usual and customary fees from then on. The insured has to remember that any charges above what are considered as usual and customary by the insurance company will have to be paid for by the insured. Lifetime limit - if the insured has a lifetime limit of $2 million, it means the insurance company will only cover costs up to $2 million during that person's lifetime. Ideally, one should have a lifetime limit of at least $2 million

14. Types of Health Insurance Plans Health Maintenance Organizations deliver care directly to the insured. The insured goes directly to an HMO's medical provider to see health care professionals. The insured does not pay for each individual service that is received. A set premium is paid to the HMO, which in return offers a range of services, including preventive care. A primary care physician (general practitioner, GP, or family doctor), who is affiliated with the insured's plan usually coordinates the care. In the majority of cases, the HMO will only provide coverage to specialists within the provider network that are referred by the primary care physician. The HMO will nearly always insist that the insured receive care from health care professionals, laboratories and medical centers which are within its network of providers. The HMO will have negotiated a list of fees for each medical service with them. This is done to keep costs at a minimum. According to the majority of health insurance advisers, HMOs are usually the cheapest kind of health insurance plan. Health Maintenance Organizations (HMO)

15. Types of Health Insurance Plans A PPO is in many ways similar to an indemnity plan - the insured can see any doctor whenever they like. The Preferred Provider Organization gets together with health care providers, health professionals and laboratories and negotiates preferential prices. The providers that come to agreed deals with the PPO then become part of its network. Copayments - when the insured visits a doctor who is within the PPOs network, they make a copayment (pay a fixed amount). When the doctor is not in the network, the PPO will still pay for some of the fees, usually at least 70%, and the insured has to cover the balance, which is known as the coinsurance, plus the copayment. Deductibles - the insured may have to cover a certain amount of the expenses before the PPO can reimburse. As with indemnity plans, deductibles might range from up to $300 per year per person or $500 to $1,000 per whole family. When deductibles are high, premiums tend to be comparatively low. Self-referrals - an attractive part of PPOs for many people. You can see the doctor of your choosing, including specialists not included in the insurer's network, without having to be referred to them by a primary care physician, for example. Preferred Provider Organization

16. Types of Health Insurance Plans A POS Plan is like a hybrid of an HMO and a PPO. The insured can chose to either have a general practitioner coordinate their care, or opt to go directly to the "point-of-service". When the insured requires medical care, there are usually two or three different choices, and they depend on what type of POS Plan is in place:. Through a primary care physician - similar to an HMO plan. The insured is just required to make a copayment. PPO network provider services - the insured can receive care from a PPO provider that is within the PPO's network. The insured will have to make a copayment, and may also be liable for coinsurance (e.g. the insurer pays 80% of the bill and the insured the remaining 20%). Services from non-network providers - some of the medical expenses will be reimbursed. It is important that the insured reads the Benefit Summary carefully, where who pays for what, and how much, should be clearly laid out. There will usually be a copayment and a higher coinsurance charge. Point-of-Service Plans

17. Types of Health Insurance Plans These are tax-free savings accounts aimed at building up coverage for future medical expenses. Only patients with a high-deductible plan and currently have no other insurance plans are eligible. This type of plan is useful for those who are seeking some kind of protection, do not envisage having any or many ongoing medical costs, and would like to be ready for an emergency or catastrophic healthcare cost. Small businesses may find HSAs a useful alternative to the more traditional health plans on the market. In general, health plans with high-deductibles have cheaper premiums; however, out-of- pocket costs are much higher. To compensate for that, the insured can contribute a certain amount of money to a tax-advantaged account - the amount as well as the details of tax benefits vary from year to year. The contributions can be used to reduce the insured taxable income. If payments are made by an employer on behalf of an employee, they are tax free. The money in the HSA plan can be used at any time for approved medical expenses. An HSA plan can also act as a top-up for expenses the other paired plan does not cover, such as hearing aids. If the money is not being used, it can be invested; any investment growth is tax free, as long as the account holder only uses the money for medical expenses. Health Savings Accounts

18. Public Insurance Medicaid Medicaid is a government funded health insurance coverage program operated by a state with financial assistance from the federal government. Medicaid is a low or no cost insurance plan for low income residents. Medicare Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

19. Public Insurance SCHIP The State Children's Health Insurance Program (SCHIP) – now known more simply as the Children's Health Insurance Program (CHIP) – is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children. The program was designed to cover uninsured children in families with incomes that are modest but too high to qualify for Medicaid. Indian Health Service. The Indian Health Service (IHS), an agency within the Department of Health and Human Services, is responsible for providing federal health services to American Indians and Alaska Natives TRICARE TRICARE is a health care program of the United States Department of Defense Military Health System.Tricare provides civilian health benefits for military, military retirees, and their dependents. Veterans Health Administration The veterans health administration (VHA) is a constituent of the United States Department of Veterans Affairs (VA). It is a tool for executing the medical assistance program of the VA. The medical assistance programs are implemented through the various VA outpatient clinics, hospitals, medical centers and nursing homes.