Health Insurance Policy

A contract between an insurance company and an individual

Insurance offsets out of pocket expenses for healthcare services.

How to Insurance

1. Choose a health plan company

2. Pay monthly premium

How to Use Insurance

1. Pay money

2. There is a set amount from the contract you have to pay

3. Pay for health care until insurance takes effect

4. Percentage of next medical related cost gets paid by insurance

5. Next year pay deductible again.

Organizations and Laws

Patient Protection and Affordable Care Act (PPACA)

ObamaCare. Signed into law in 2010. It’s goal was to make health insurance available to everyone.

Medicare

• The nation’s largest health insurance program

• Covers the elderly, and retired individuals

• 3 main parts/types:

  • Part A : Hospital

  • Part B : Medical Insurance

  • Part D : Pharmaceutical

Medicaid

• Program funded by the STATE and FEDERAL government, but states have authority to establish program rules

• Covers individuals with low income, children, and those who are disabled.

Children’s Health Insurance Program (CHIP)

• Provides insurance to the under insured children of working families.

• These families are in the middle of able to pay for private insurance, but not eligible for medicaid.

Health Maintenance Organization (HMO)

• Focused on managed care

• Out of pocket expenses are set

• Specialty treatment is available but must have a referral

• Requires a Primary Care Provider (PCP) that is the ‘gatekeeper’ to a patient’s healthcare. The manager ALL care.

• If you use a doctor that is NOT contracted with the insurance company they can DECLINE to pay for services.

Preferred Provider Organization

• Focus on patient’s choice

• Physicians contract services for a set fee are listed as a preferred provider. So the patients get to choose from this list of providers to see

• Insurance company pays a SET amount and the patient pays a SET amount called a co-pay

• Primary Care Physicians are NOT required

• PPOs tend to have a HIGHER monthly premium in exchange for the flexibility to choose providers both in, and out-network WITHOUT a referral

Managed Care

• Goal : All healthcare provided must have a purpose

• Every effort is made to provide preventative care, and early diagnosis to avoid high costs of treating disease.

  • Examples include

    • Routines physical exams

    • Well-baby care

    • Immunizations

    • Wellness education

• Insurance companies create a network of doctors, specialists, therapists, and healthcare facilities that provide care at the most reasonable cost.

• HMO’s and PPO’s are the main providers of managed care.

Terminology

• Premium

• Deductible

• Co-Insurance

• Co-Pay

• HMO

• PPO

• Medicare

• Medicaid

• Worker’s Compensation

• TRICARE

• Pr-existing condition

• Referral

• Beneficiary

• Managed care