1. Health Insurance Can name some carriers???

2. Insurance
A person buys insurance and the insurance provider agrees to pay or reimburse for the costs of medical care
Babylon (1750 BC) – merchant ships
Great Fire on London (1666)
13,200 houses were burned to the ground
Gambling analogy
In 2006, there were 47 million people in the U.S. (16% of the population) who were without health insurance for at least part of that year

3. Different Types of Insurance
Hospitalization Insurance- Specifically pays for hospitalization
Surgical Insurance – Specifically pays for fees associated with surgery
Disability Insurance – Pays for loss of income due to accident or illness
Usually only a percentage of your salary
Life Insurance
Car Insurance
Alien abduction insurance??????

4. History of Health Insurance
Before the development of medical expense insurance, patients were expected to pay all other health care costs out of their own pockets
Almost impossible now with the high cost of health care
Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against injuries arising from railroad and steamboat accidents
The first employer-sponsored group disability policy was issued in 1911

5. Group vs. Individual Insurance
Group Policies – provided by employer
you employer pays for all or most of you insurance plans cost
All of the employees at you work have the same health insurance options as you do
Commonly called “benefits
Individual Policies – you buy the policy yourself
Very similar to the way you get car insurance
About 9% of the population gets their health insurance this way

6. Health Insurance Terms
Provider – a hospital, doctor or anyone else who provides a service
Network – Group of hospitals and/or doctors that jointly provide care to a given group of patients covered by health insurance
Major Medical - form of medical insurance designed to supplement a basic medical expense plan in the event of extraordinary medical expenses
Extreme illness or disability
Covered Expense – something that the insurance plan will pay for
Exclusions –Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket.

7. Insurance Terms Continued
Pre-existing Condition – A health Problem that a person has before they are covered by a certain policy
The policy may or may not pay for expenses associated with these conditions
Waiting Period – Predetermined amount of time between when your employment begins and when your insurance coverage actually begins
You are not covered during this time

8. Your Costs
Premium – The amount the policy-holder pays to the health plan each month to purchase health coverage
Deductible -The amount that the policy-holder must pay out-of-pocket before the health plan pays its share
Deductible could be yearly or could be per injury / illness
Example:
Your yearly deductible - $500.00
Your medical Bill – $2,500.00
Insurance company pays $2,000.00
You pay $500.00
Copayment The amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service.
For example, a policy-holder might pay a $45 copayment for a doctor's visit, or to obtain a prescription.
A copayment must be paid each time a particular service is obtained

9. Example of what a plan would look like…

10. Managed Care
Organized system of health care services designed to control health care costs
One of the most characteristic forms of managed care is the use of a panel or network of health care providers to provide care to enrollees
Managed care usually involves:
Standards for selecting providers
An emphasis on preventive care
Financial incentives to encourage enrollees to use care efficiently

11. Two main kinds of Managed Care Insurance
HMO – Health Maintenance Organization
PPO – Preferred Provider Organization

12. HMO
HMOs manage their patients' health care by reducing unnecessary services
To achieve this, most HMOs require members to select a primary care physician (PCP)
This physician acts a a gatekeeper to medical services
most medical needs must first go through the PCP, who authorizes referrals to specialists or other doctors if deemed necessary
This is called a “referral”
Emergency medical care does not require prior authorization from a PCP

13. HMO’s and non-network
Most HMO’s will only pay for medical bills for you PCP of for services your PCP approves through referral
HMOs typically provide no coverage for care received from non-network physicians (with exceptions for emergency care while traveling, etc.).

14. HMO Public Image
HMOs often have a negative public image due to their restrictive appearance.
HMOs have been the target of lawsuits claiming that the restrictions of the HMO prevented necessary care
Usually a “cheaper” plan

15. PPO – Preferred Provider Organization
Organization of medical doctors, hospitals and other health care providers
“network” or “preferred provider”
Network is contracted with an insurer to provide health care coverage at a reduced rate (substantial discount)
Some surgeries or procedures may need to require pre-approval by the insurance company

16. PPO’s and non-network
PPO may reimburse 90 percent of costs for care received within the network, but only 70 percent of costs for non-network care

17. PPO Public Image Usually allow more freedom than HMO
Usually a more expensive type of insurance plan
Networks can change
If you choose to get medical care from a provider who is out of network….It costs you more money

18. Federal Programs for Health Coverage
Medicaid – health insurance for people with lower incomes
Funded by state and federal government
Eligibility rule vary state to state
Example of Medicaid requirements
You're a pregnant woman who meets income requirements. For example, a family of four making $23,225 a year or less qualifies.
Your family's assets are less than $2,000

19. Federal Programs for Health Coverage
Medicare –Government health coverage for people 65 years or older
***In many cases Medicare pays a portion of the person’s health care cost. The rest is paid by the persons Medicaid or supplemental insurance plan

20. WIC Women Infants and Children
Program that helps mothers and children with medical bills
Prenatal care
Preventive screenings
Immunizations
Pay for “proper” food and medicines

21. Single Payer System National Health Care
Centrally controlled heath care system (government)
Taxes
Sometime requires supplemental health insurance
U.S. ranks
22nd in infant mortality
46th in life expectancy
37th in health system performance, between Costa Rica and Slovenia

22. Bad system or Broken System?
In a 2007 comparison by the Commonwealth Fund of health care in the U.S. with that of Germany, Britain, Australia, New Zealand, and Canada, the U.S. ranked last on measures of quality, access, efficiency, equity, and outcomes
30 percent of U.S. health care dollars, or more than $1,000 per person per year, went to health care administrative costs

24. Federal Programs for Health Coverage
COBRA
Consolidated Omnibus Budget Reconciliation Act (1985)
If you lose your job you may continue to pay your insurance premium and maintain coverage for up to 18 months
This also applies to children on insured employees
If a child somehow looses full-time student status that child may make a COBR payment to maintain coverage

25. Coinsurance Instead of paying a fixed amount up front (a copayment), the policy-holder must pay a percentage of the total cost.
For example, the member might have to pay 20% of the cost of a surgery, while the health plan pays the other 80%. Because there is no upper limit on coinsurance, the policy-holder can end up owing very little, or a significant amount, depending on the actual costs of the services they obtain.

26. Sicko