Unit Seven- Health Insurance Prof. Carolyn Dragseth, Esq. PA342 Insurance Law

TO DO in Unit Seven Attend Seminar. Answer BOTH discussion questions on the discussion board.

LOOKING AHEAD TO UNIT 8 Final Exam Essay (DUE IN UNIT 8) Write 250-word answers for both of the following questions. Please write in full paragraphs and sentences, using details and analysis to support your answers. Identify and describe characteristics of the different types of health care policies, detailing their coverage. Elaborate on the different procedures excluded from health insurance coverage. Imagine that you are an auto insurance salesperson. A prospective customer wants to learn more about automobile insurance. Take a moment to describe the four major types of automobile insurance coverage.

Health Insurance in General Health insurance was not really popular until after WWI. Interesting fact, a group of schoolteachers at Baylor (in 1929) is credited as creating the forerunner to Blue Cross and Blue Shield which is a fee-for-service coverage. Commercial insurance companies offer payment of a specified maximum dollar amount per day. In 1965 Medicare was established to provide medical expense insurance coverage to those over 65.

Health Insurance in General Medicaid is a state-federal medical assistance program for low income individuals. Managed Care Organizations.

FIELD TRIP Take the next ten minutes to search the web. Compile a list of possible types of health insurance. Get a short definition of each. When you return to the classroom we will share our knowledge.

Health Maintenance Organizations (HMO) Provides for the financing of the health care and also delivers that care. Operate their own hospitals and clinics and have contracts with physicians and other health care professionals.

An Overview of an HMO “A health maintenance organization, or "HMO", is a prepaid health plan. As an HMO member, you pay a monthly premium. In exchange, the HMO provides comprehensive health care for you and your family, including doctors' visits, hospital stays, emergency care, surgery, laboratory (lab) tests, x-rays, and therapy. The HMO arranges for this health care either directly in its own group practice and/or through doctors and other health care professionals under contract. Usually, your choices of doctors and hospitals are limited to those that have agreements with the HMO to provide health care. However, exceptions are made in emergencies or when medically necessary. There may be a small co-payment for each office visit, such as $5 for a doctor's visit or $25 for hospital emergency room treatment. Your total medical costs will likely be lower and more predictable in an HMO than with fee-for-service health insurance. Because HMOs receive a fixed fee for your covered medical care, it is in their interest to make sure you get basic health care for problems before they become serious. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. The range of health services covered varies in HMOs, so it is important to compare available HMO plans. Some services, such as outpatient mental health care, often are provided only on a limited basis. Many people like HMOs because they do not require claim forms for office visits or hospital stays. Instead, members present a card, like a credit card, at the doctor's office or hospital. However, in an HMO you may have to wait longer for an appointment than you would with a fee-for-service health insurance plan.” Source:

Preferred Provider Organizations This is a network of health care providers (doctors and hospitals) that the insurance company contracts with to provide services. Allows for more individual choice (you can see if your physician is in the network) or you can see an out of network provider if you desire as well.

An overview of a PPO “How does a PPO plan work? The insured members pay a co-payment at the time of each medical service. For example, at the time of an office visit to a physician, the patient pays $20. Each person will also have a yearly deductible to pay out of his/her pocket, before the insurance company will start paying medical fees. The insurance usually pays a percentage of the medical fees (often 80%) for the in-network doctor, with the patient responsible for the remainder of the bill. If the person wants to see an out-of-network doctor, he/she may do so without permission; but the deductible for out-of-network services may be higher and the percentage the insurance will pay may be lower. In other words, the patient will be responsible for a greater part of the fee. This encourages the people insured with a PPO to use the physicians, other medical providers and hospitals in their network. Advantages of a PPO Plan Advantages of a PPO include the flexibility of seeking care with an out-of-network provider if so desired, even though it is more out-of-pocket expense for the patient. PPO networks also have prescription services which provide prescription drugs at a reduced cost. The overall premium for a PPO is less than for individual health coverage and will often include more covered medical services. There is a large network of medical providers representing large geographic areas.” Source:

Point of Service Plans They operate like a PPO since there is choice in the provider but will have to pay a higher proportion of the costs when he or she uses a provider outside of the network. Health services managed through a network of primary care physicians or gatekeepers.

An overview of POS “A health benefits plan that provides coverage for care received from both participating providers and non-participating providers. In many POS plans, patients whose care is directed through referrals from their primary care physician (PCP) receive a higher level of benefits, while patients who go directly to other physicians or facilities receive a lower level of benefits.” Source: ary.html

MENTAL BREAK

Other Health Insurance Topics Medicare Medicaid COBRA HSA

Medicare Covers most people over the age of 65 and disabled individuals who meet certain eligibility requirements. Best source of information: Here is an overview of Medicare benefits: basics/medicare-benefits/medicare-benefits- overview.aspxhttp:// basics/medicare-benefits/medicare-benefits- overview.aspx

Medicaid Title XIX of the Social Security Act is a federal-state program for the assistance of needy individuals. Best resource for this is: pdfhttp:// pdf This is affected by how each state runs their program so check with your state in regards to specifics.

COBRA Requires that employees and certain beneficiaries be allowed to continue their group health insurance coverage following a qualifying loss of coverage. More information visit: plans/cobra.htm plans/cobra.htm

HSA Health Savings Accounts allow individuals to make tax sheltered contributions to a fund used to cover medical expenses. Must be covered by a high deductible health care plan (1110 for individual or 2200 for families) Any insurance company or bank can be an HSA trustee. A good information source is affairs/hsa/faq_basics.shtml affairs/hsa/faq_basics.shtml

QUESTIONS???