1. STANDARD 6
Differentiate among the methods of payment for healthcare in the United States. Include private and state or federal insurance, health savings accounts, managed care, Veteran’s Health Administration, Military Health System/TRICARE, and long- term care.
(TN Reading 1, 9)
Copyright © 2004 by Thomsom Delmar Learning. ALL RIGHTS RESERVED.

2. STD 6 BREAKDOWN
Differentiate among the methods of payment for healthcare in the United States.
Private
State or Federal Insurance
Health Savings Accounts
Managed Care
Military Health System: TRICARE
Veteran’s Health Administration
Long Term Care

3. Why do you need health insurance in the U.S.?
In the U.S. (unlike most of the world), insurance is privatized.
Seeking medical treatment for illnesses or accidents would be very expensive without health insurance.
Health insurance offsets the cost of doctor bills, surgery, hospital, laboratory and x-ray fees, and pharmacy costs

4. SOCIO-ECONOMICS
Study of how economics is affected by society, culture, and politics.
link between poverty and poor health
Those who cannot afford doctor visits, medicine, vaccinations, and other medical treatments are more likely to become sick than those who can afford these services.
Many people purchase health insurance through their employer. The employer and the employee split the premium payment. This system makes the expense of health insurance more manageable.
However, people who are not employed do not have these medical benefits.
Not all employers offer health coverage for their employees.
Individual insurance policies can be expensive, and many people cannot afford to purchase them.
Socio-economics has revealed the need for medical assistance for the elderly, disabled, and poor.

5. Health Insurance TERMINOLOGY
Provider: the insurance company
Subscriber: you (the insured)
Premium: monthly fee that is paid to an insurance company to provide health coverage.
Deductibles; amount the patient must pay before the insurance policy begins to pay

6. Health Insurance TERMINOLOGY
Co-insurance: specific percentages of expenses are shared by the patient and insurance company. EXAMPLE: 80%/20%
Insurance company pays 80% of covered expenses
Patient pays the 20% that is remaining
Co-payment: specific amount of money paid by patient for particular service.
Patient pays $10.00 co-pay for office visit.
Pre-existing condition: illness or injury which happened before you purchased your insurance policy. (Examples are: diabetes, cancer, pregnancy)
Out-of-pocket - medical cost which the subscriber (YOU) is responsible for. These are in addition to the cost of the premium. (Examples are deductible, co-pays, etc)

7. REIMBURSEMENT
Reimbursement – when a provider pays for expenses after they have been paid directly by the policy holder or another party
Health insurance agencies do not always reimburse the full amount charged for services. Physicians may charge any amount for the services they provide. However, insurance agencies may have a set limit for the amount that they will reimburse.
Example, a doctor may choose to charge $200 for a routine check up. However, an insurance agency may have a set limit of $150 for a routine check up. The remaining $50 may be covered in one of two ways:
The doctor will “absorb” the loss. This means that the doctor will drop the $50 charge and accept $150 from the insurance company as full payment for the check up.
The doctor will charge the patient for the remaining $50. In this way, the doctor will receive the full $200 payment for the check up.
It is important for patients to be proactive with their health care. They must ask questions and research reimbursement amounts. Otherwise, patients may be required to pay a portion of the bill.

8. MANAGED CARE
health care delivery system (network of doctors & agencies) organized to manage cost, utilization, and quality.
Most dominant health care delivery system in the United States and available to most Americans.
Managed care is built on two primary concepts:
promote good health
practice preventive medicine.
MC GOAL: reduce the cost by providing quality care at lowest price possible, & maintaining a healthy lifestyle.

9. MANAGED CARE
Managed care plans offer medical services through a system of health care providers. The system of providers offer services at reduced rates.
People who are insured through a managed care plan MUST receive treatment from physicians within this system in order to get the reduced cost.
Managed care offers reduced rates for medical services through a network of health care providers.

10. MANAGED CARE
1)Developed in response to rising health care costs.  2) A second opinion is often required before treatment can be provided, with the focus on preventive care 3) managed care NETWORKS are required to provide quality care at the lowest possible cost while managed care is required to provide quality care at a reasonable rate.
Three basic types of managed care providers.
Health Maintenance Organizations
Preferred Provider Organizations
Point of Service

11. Health Insurance TERMINOLOGY
Out-of-Network
A health care provider or facility that does not have a contract with the insurance company.
Treatment at these facilities will cost the patient more.
In-Network
A healthcare provider or facility that has a contract with the insurance company.
They provide services at a reduced cost to subscribers.

12. HMO & PPO PPO-Preferred Provider Organization
HMO – Health Maintenance Organization
type of managed care plan which charges a monthly fee covers health care services approved by doctors who are affiliated healthcare providers.
PCP is assigned
PCP will determine if , when and to whom you will go if more specialized treatment is necessary (serves at gatekeeper)
self-employed disadvantage: you can only go to certain HMO physicians if not you have to PAY!
PPO-Preferred Provider Organization
Type of managed care, usually provided by large companies who have a contract with certain health care agencies.
Patient may see any doctor on a list of PCPs (Primary Care Providers)
Patient may visit specialist without referral from a PCP
provides certain types of healthcare at reduced rates
Advantage for self-employed

13. POINT OF SERVICE or POS
Point of Service, or POS, plans are often considered a type of HMO.
However, because of their increasing popularity in recent years, POS plans have developed into their own division of medical coverage.
Clients must pay a monthly premium.
Clients must chose a primary care physician
In-Network Services, there is no deductible and co-payments are low.
Specialists must be pre-approved by the PCP: can be non-network physicians, but coverage may be limited.
POS plans require that a co-payment and a deductible are paid for non-network services

14. HEALTH INSURANCE
Defined as: type of insurance offered by private insurance companies or the government that covers health care expenses incurred by policyholders for necessary medical care.
Your health insurance decision is not whether to obtain it, but which health plan to purchase and how much coverage to purchase.
Rising cost of health care is good for the economy, but the expenses are a burden for most individuals and families.
Costs of health care rising faster then any other cost of living

15. HEALTH INSURANCE
Health care: Profitable industry in the United States.
Health care expenses make up almost 15 percent of the United States’ gross national product.
In the 1920’s, the United States developed a system of health insurance to help cover the cost of medical expenses. Health coverage is offered by private health insurance agencies. Individuals make payments to the agencies. When medical services are needed, the agency covers part or all of the expenses. The amount of coverage varies according to the insurance policy.

16. INDIVIDUAL & GROUP HEALTH INS
Health insurance policies may be purchased in two basic forms:
1. Individual: when a person purchases a policy and agrees to pay the entire premium for health coverage.
2. Group: generally purchased through an employer.
The premium is split between the employer and the person being insured.
Medical insurance is an important benefit of employment.
Group insurance is almost always less expensive than individual insurance.

17. Private Health Insurance
Defined as health insurance that can be purchased from private insurance companies to provide coverage for health care expenses
EXP: BLUE CROSS BLUE SHIELD
Expenses not covered by private insurance plans should be included in your budget
Flexible spending account: account established by the employer for the employee to use pretax income to pay for medical expenses
Certain amount of funds can roll over into the next year

18. ARTICLE REVIEW Understanding the U.S. Health Care System
nderstanding-us-healthcare-system/
How many Americans have some type of health insurance coverage?
How many Americans are non-insured?
How would you fix the US Health Care System?
Copyright © 2004 by Thomsom Delmar Learning. ALL RIGHTS RESERVED.

19. PATIENT PROTECTION & AFFORDABLE CARE ACT (PPACA)
Patient Protection and Affordable Care Act(PPACA)
Most commonly called the Affordable Care Act (ACA) and nicknamed “Obamacare”
United States federal statute enacted by President Barack Obama on March 23, 2010
‘Obamacare’ is a market for purchasing private insurance
Designed for people with income that makes them ineligible for Medicaid and Medicare

20. GOVERNMENT PROGRAMS
In the 20th century, the United States government began to realize the need for public medical assistance.
In 1965, President Lyndon B. Johnson instituted two federal medical assistance programs to help those without health insurance.
Medicaid
Medicare

21. MEDICARE Medicare; federal government program
Provides health insurance to:
people over age 65
any person with a disability who has received Social Security Benefits for at least two years.
end-stage renal disease
Part A: covers inpatient care in hospitals or nursing facilities and some home health
Part B: is optional coverage & offers coverage for doctors services, outpatient treatments, therapy, and other health care.

22. MEDICARE
Medicare will not cover all of an individual’s health care expenses. The insured persons are required to pay a yearly deductible.
After the deductible, Medicare will cover 80% of all expenses. Which means that insured persons must pay the remaining 20%.
Many people cannot afford to pay the 20% charge. An additional form of insurance called Medigap may be purchased to help cover the remaining expenses.
Medigap insurance also MEDICARE PART D: insurance provided by private insurance companies to cover medical/drug (prescription) expenses that are not covered by Medicare

23. HIPAA Health Information Portability and Accountability Act
U.S. Department of Health and Human Services established the Standards for Privacy for Individually Identifiable Health Information (the "Privacy Rule") to implement the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
HIPAA is designed to protect everyone’s personal health information.
The Privacy Rule is a flexible way to balance protecting individuals' health information with allowing health information to be used to provide high- quality care and promote public health.
Information spread outside of the necessary healthcare covered entity must obtain written permission from the patient.

24. MEDICAID
Medicaid is a need-based FEDERAL program administered on a state-by-state basis. VOLUNTARY for states; they may or may not choose to participate in.
Recipients must meet federal guidelines
Medicaid provides medical assistance to individuals and families who are “needy,” and each state must determine its own definition of “needy.”
Low income
Disabled or Blind
Children who qualify for assistance

25. MEDICAID Individuals with low income
APPLICANTS WHO ARE ELIGIBLE:
(MOST STATES)
Individuals with low income
Individuals who are physically disabled or blind
Low income families with children who qualify for public assistance
Pregnant women in low-income families
Families with adopted or foster children
Adults with certain chronic or debilitating diseases
Adults who receive social security benefits
Medicaid is not guaranteed to every low-income individual.
If a low-income individual does not have children or is not disabled, this person may be unable to receive any medical insurance.
40% to 60% of the poor do not qualify for Medicaid. If a low- income individual does not have children or is not disabled, this person may be unable to receive any medical insurance.

26. MILITARY INSURANCE: TRICARE
The military medical care system is:
well-organized
highly integrated
comprehensive
covers preventative care
One of the largest and oldest (1946) organized health systems in the world
TRICARE: insurance plan that the United States government provides to all military personnel.
Provides care to all active duty members and their families, survivors of military personnel, and retired members of the armed forces.

27. VA HEALTH CARE SYSTEM over 1,100 sites 172 hospitals
206 counseling centers
40 residential care facilities
73 home health programs, and
provides care to 3.6 million
Employs over 182,000
Affiliates with
13,000 physicians
53,000 nurses
3,500 pharmacists
Budgets over $20 billion

28. Health insurance plan that provides treatment for workers who are injured on the job.
Plan is administered by the state
Employers are required to make payments for workers compensation benefits if they have certain number employees.
WORKERS COMPENSATION

29. Long-Term Care Insurance
Long-term care insurance: covers expenses associated with long-term health conditions that cause individuals to need help with everyday tasks
Provided by private insurance companies
Covers care in a nursing home, assisted living facility, or at home.
Premiums quite expensive
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30. National Health Care Plan
Main Goal: ensure that all Americans can get health coverage
Various plan proposals
Costs
Potential problems
Copyright © 2004 by Thomsom Delmar Learning. ALL RIGHTS RESERVED.

31. SUMMARY STD 6
Health insurance plans do not solve all the problems of health care costs, although they can help many people pay for all or part of health care cost.
Important for individuals to know/understand what plan covers
Need for understanding of co-insurance and other restrictions the plan may have