1. 2:4 Health Insurance Plans

2. Health Insurance Plans
Health care costs are increasing faster than other costs of living
To pay for the cost of health care, most people rely on health insurance plans
- without insurance, the cost of an illness can mean financial disaster for an individual or family
Health Insurance- payment for health care expenses, which may or may not occur, in return for a specified payment in advance
Health insurance plans are offered by several thousand insurance agencies
Common example: Blue Cross / Blue Shield

3. Health Insurance Plans
Premium: fee the individual pays for insurance coverage
When the insured individual has health expenses covered by the plan, the insurance company pays for the services
- Amount of payment & type of services covered vary from plan to plan
Deductibles: amounts that must be paid by the patient for medical services before the policy begins to pay
Co-insurance: requires that specific percentage of expenses are shared by the patient and insurance company
Example: In an 80/20 percent co-insurance, the company pays 80% & the
patient pays the remaining 20%
Co-payment: specific amount paid by patient for a particular service
Example: $10 for each office visit or $50 for ER visits

4. Health Insurance Plans
Many have insurance through their employer, where premiums are paid by the employer \ the employee (the insured) also pays a percentage in most cases
Private policies are also available for purchase by individuals
HMO’s - The insured is required to use ONLY the HMO-affiliated health care providers (doctor / lab / hospital) for care. If the insured individual chooses to use a nonaffiliated provider, they must usually pay for the care
Preferred Provider Organization (PPO) – insurance plan usually provided by large companies which form a contract with providers so the insured individuals get a lower rate – if another nonaffiliated provider is used the PPO may require
co-payments of 40-60%

5. Health Insurance Plans
Two main government insurance plans are Medicare & Medicaid
Medicare - Federal insurance providing coverage to eligible patients:
- 65 and older
- Disabled
- End Stage Renal Disease (ESRD)
*Medicare only pays for 80% of coverage
*Medigap policies help pay expenses not covered by Medicare
Medicaid – Jointly funded by federal & state government but operated by
individual state; usually covers those with low income,
disabled, or blind – offers medical, dental & eye care

6. Health Insurance Plans
Workers’ Compensation – health insurance plan providing treatment for workers injured on the job
- administered by the state, and payments are made by employers & state
- also reimburses worker for wages lost because of on-the-job injury
TRICARE – U.S government health insurance plan for all military personnel
- provides care for all active duty members & their families, survivors
of military personnel, and retired members of the Armed Forces
- The VA provides for military veterans

7. Managed Care
An effort to ensure health care money is spent efficiently, rather than wastefully
Principle: All health care provided to a patient must have a purpose
Verification of services is required before care can be provided
HMOs and PPOs are the main providers of managed care, but many private insurance companies are establishing health care networks to provide care to their subscribers
The patient who is enrolled in a managed care plan receives quality care at the most reasonable cost but is restricted in choice of health care providers