1. HEALTH INSURANCE
HSE STANDARD 5

2. Bell Work
Below is a chart that lists procedures on left and possible costs on the right. How much do you think these procedures on the left cost? Choose the cost that you think matches the procedure.

3. CHECK YOUR ANSWERS
Swap papers and check your answers:

4. STANDARD 5
Calculate the costs of a range of health insurance plans, including deductibles, co- pays, PPO’s and HMO’s. For a selected disease/disorder/injury, predict the total cost (including but not limited to the diagnostics, procedures, and medications involved), allowable reimbursement, and actual reimbursement under each of these plans for the course of the treatment.

5. Definitions Copy the following terms and definitions:
COINSURANCE- the amount you are required to pay for medical care in certain types of health plans after you have met your deductible. It is usually expressed as a percentage.
COPAYMENT- A way of sharing medical costs. You pay a flat fee every time you receive a medical service. The insurance company pays the rest.
DEDUCTIBLE- The amount of money you must pay each year to cover your medical care expenses before your insurance policy starts paying.
DEPENDENT- A child covered under their guardian’s insurance policy. Students can be covered under their parents policy until the age of 26 if they are unmarried and have no dependents of their own.

6. DEFINITIONS
EXCLUSIONS- Specific conditions or circumstances for which the policy will not provide benefits
HEALTH MAINTENANCE ORGANIZATION (HMO)- A health insurance plan that allows you to pay a monthly or quarterly premium in exchange for healthcare services. HMOs require you to work with a primary care physician who will direct your care and refer you to specialists as needed. They also require you to see doctors, hospitals, and labs within their network of providers.
HEALTH SAVINGS ACCOUNT (HAS)- A medical savings account that allows you to save money to pay for current and future medical expenses on a tax-free basis. In order to be eligible, you must be covered by a high-deductible health plan, not have any other health insurance, and not be claimed as a dependent.

7. DEFINITIONS
MAXIMUM OUT-OF-POCKET- The maximum amount of money you will be required to pay each year for deductibles, coinsurance and copayments. It is a stated dollar amount set by the insurance company, in addition to regular premiums.
PRE-EXISTING CONDITION- A health problem that existed before the date your insurance coverage became effective.
PREFERRED PROVIDER ORGANIZATION (PPO)- A health insurance plan that allows you to see any doctor at any time. In addition to a monthly or quarterly premium, a PPO typically requires you to make a copayment for each service you receive. Copayment for in-network providers are typically lower than for out-of-network providers.

8. DEFINITIONS
PREMIUM- The amount paid by you/your employer, in addition to copayments, coinsurance, and deductibles, in exchange for insurance coverage.
PREVENTIVE CARE- Services designed to keep patients healthy, including check-ups, well baby and adult care, immunizations, Pap smears and mammograms
PRIMARY CARE PHYSICIAN- A doctor who monitors your health, diagnoses and treats minor health problems, and refers you to specialists if another level of care is needed.

9. Cost of procedures
Would you buy something that didn’t have a price listed?
What if the store charged different prices for the exact same product?
What about medical care? How much does a doctor visit cost?
What will it cost if you break a leg and need x-rays, a cast, or even an operation?

10. Cost of procedures
Most people don’t know the real cost of health care. And sadly, prices keep increasing.
Many healthcare facilities do NOT give you the price of procedures ahead of time, which is a complaint many people have had.
The average cost in the US each person spends on healthcare is $8,000!
Medical facilities and test centers can all charge different prices. There is no universal costs for medical procedures in the U.S.

15. Two sisters, two plans

16. Two sisters
Joan and Jill love outdoor sports. On a recent ski trip, they fell off a ski lift. Each one had to have knee surgery.
Both sisters were rushed from the ski resort to an ER and then transferred to hospitals in their hometown, where they were admitted for two-day hospital stays. Because they chose different types of health insurance plans at their jobs, their coverage was different.
Help determine how much each sister had to pay.

17. Write Down

18. Two sisters Monthly Premium- $200 Annual Deductible- None
Coinsurance- None
Copayment- $100
ER Copayment- $50 (waived if admitted)
Dr. visit Copayment- $20
Monthly Premium- $100
Annual Deductible- $1,000
Coinsurance- 20% after deductible is met
Copayment- None
ER Copayment- $100 (waived if admitted)
Dr. visit Copayment- $35
JOAN’S HMO PLAN
JILL’S PPO PLAN

19. JOAN’S SCENARIO
Joan has a HMO plan. She was directed to a hospital within her HMO’s network and was limited in her selection of a knee surgeon.
The HMO has no deductible or coinsurance, which means that most of the cost of care has been prepaid through insurance premiums.

20. JILL’S SCENARIO
Jill has a PPO plan. She wanted more choice of doctors and hospitals when she was signed up for her plan. After her accident, she was able to pick any doctor and any hospital listed in her plan’s directory.
The PPO has a doctor office copay, but no copay for other services. It also has a deductible that has to be met before her insurance pays any costs. The coinsurance is then 20% of her health care costs AFTER the deductible has been met.

21. Annual premiums
In order to calculate how much each sister much pay annually, you take their monthly premium and multiply is by 12 to get the yearly total.
This total is the minimum cost for health insurance each year.

22. Ski accident costs Emergency Room Visit= $250
ALL COSTS LISTED ARE PRIOR TO INSURANCE BEING APPLIED:
Emergency Room Visit= $250
2-day Hospital Stay= $4,775
Follow-up Doctor Visit = $160
Total Cost w/o Insurance = ???

23. Calculating costs
When figuring out how much each sister paid for this accident be sure to include the following costs:
Annual Deductible (delete this from their first cost)
Coinsurance
Co-pay for hospital
Co-pay for ER
Co-pay for Doctor

24. Two sisters, two plans Complete the Two Sisters, Two Plans Worksheet
Fill in both charts and answer the questions at the bottom.

25. Assignment
Copy vocabulary words at beginning of lecture into notebook.