Basics of Health Insurance

1. Basics of Health Insurance

2. The Purpose: • To help offset the cost of medical care • Protection against financial losses resulting from illness or injury • Covers services and procedures that are considered medically necessary • Covers preventive care

3. DOES NOT COVER • Elective Procedures such as: • Breast Augmentation • Abdominoplasty • Blepharoplasty • Rhinoplasty • Botox • Other elective, non-medically necessary procedures

4. Different types of Insurance • Health Insurance for sickness or injury • Coverage for accidents • Disability • Hospitalization • Accidental death • Dismemberment

5. Here’s the lowdown- • The insuredis also known as the policy- holder • Can be an individual, group or employer • A set amount is paid monthly to the Insurance company, this is called a premium • The insured receives benefits, (payments for medical coverage) and is known as the beneficiary • A dependent is the spouse or child of the insured who is covered under the policy

6. And More… • Or to obtain an Authorization for an upcoming medical procedure • The Medical Assistant may need to call the Patient’s Insurance Compnay to verify the Eligibility of the patient’s coverage

7. Insurance Companies • This is called a • -Deductible • Many plans now require a co-payment from the patient at the time of their appointment. $10-$25.00 • A carrier is the Insurance Company who “carries” the coverage • According to the policy the patient pays a portion of the amount owed-

8. Government Plans • MEDICARE part B • Is for patients 65 and over. • Military dependents are covered by TRICARE • CHAMPVA is coverage for surviving spouses, children • Many large groups of people are covered by government plans.

9. Other: • Medical Savings Accounts (MSA’s) • A type of self insurance where the insured can buy health insurance and make tax free deposits to an MSA • MEDICAID is coverage for individuals who cannot pay for medical coverage themselves • Estab. 1965

10. Types of Plan Benefits • Hospitalization • Basic/Major Medical Vision • Dental • Long term care • -Covers all or part of the room, medicines, care, surgery, etc., -Inpatient/Outpatient Radiology, laboratory,

11. Disability- weekly or monthly cash payments are provided to employee/policy holders who become unable to work as a result of accident or illness • Long term care- chronically ill, disabled or mentally ill Disability Insurance

12. Who decides how much to pay? • Usual • Customary • Reasonable • Some Insurance companies agree to pay on the basis of all or a part of the physician’s UCR fee.

13. Managed Care • Managed care is an umbrella term for all healthcare plans that provide healthcare in return for preset, scheduled payments, • To coordinate healthcare through a group of physicians & hospitals

14. HMO’s • Advantages: • 1. costs are contained • 2. fees are set • 3. covers most preventive care • 4. less out of pocket for patients • Health • Maintenance • Organization- • Provide comprehensive healthcare to an enrolled group for a fixed periodic payment

15. HMO’s • All healthcare may be managed at one facility • Disadvantages: • 1. Medical care access is limited • 2. choice of physician is limited • 3. more paperwork • 4. Pre-Auth required

16. Other types of companies… • EPO • Exclusive Provider • Organization • “Exclusive” because employers agree to one plan • PPO • Preferred • Provider • Organization • “Preferred” because it is based on fee for service, with preferred physicians • Co-pay/80-20% EPO PPO

17. Insurance Companies • Blue Cross/Blue Shield • Cigna • Aetna • Kaiser Permanente • Humana • United Healthcare • Coventry • Assurant • Medicare • Medicaid • Tricare • ChampVa Private plans Government plans