Individual Insurance

Transcription

1 Health Insurance

2 Health Insurance against loss by illness or bodily injury. Health Insurance provides coverage for medicine, visits to the doctor or emergency room, hospital stays and other medical expenses. Policies differ in what they cover, the size of the deductible and/or co-payment, limits of coverage and the options for treatment available to the policyholders.

3 Individual Insurance Individual health insurance covers the medical expenses of only one person or family. Unlike group insurance, you purchase individual insurance directly from an insurance company. Can be expensive Preexisting conditions will not be covered

4 Group Health Insurance Group health insurance, is a single policy covers the medical expenses of many different people. All eligible people can be covered by a group policy, regardless of age or physical condition. The premium for group insurance is calculated based on the characteristics of the group as a whole, such as average age and degree of occupational hazard.

5 How do you get group health insurance? Find out whether you are eligible Apply for coverage; you must apply during the specified eligibility period. For employer-sponsored health insurance, this is often the first 30 days of your employment, or the first 30 days following your initial probationary period. For associational insurance, this may be the first 30 days of your membership in the group.

6 What are the drawbacks to group coverage? You can't customize your policy. You may not have the freedom to have provisions included or excluded, Your deductible amount and co-payment percentage are determined in advance.

7 Advantages of a HMO Low out-of-pocket costs Focus on wellness and preventative care Typically no lifetime maximum payout

8 Disadvantages Of HMO Tight controls can make it more difficult to get specialized care; As an HMO member, you must choose a primary care physician (PCP). Your PCP provides your general medical care and must be consulted before you seek care from another physician or specialist. This screening process helps to reduce costs both for the HMO and for HMO members, but it can also lead to complications if your PCP doesn't provide the referral you need. Care from non-hmo providers generally not covered; Except for emergencies occurring outside the HMO's treatment area, HMO members are required to obtain all treatment from HMO physicians. The HMO will not pay for non-emergency care provided by a non-hmo physician. Additionally, there may be a strict definition of what constitutes an emergency.

9 Preferred Provider Organizations PPO Focuses on preventative care and implementing utilization management controls. PPO members generally pay a small fee for services as they are rendered. The PPO sponsor (employer or insurance company) generally reimburses doctor or health care provider.

10 Advantages of a PPO Free choice of healthcare provider Out-of-pocket costs generally limited

11 Disadvantages of a PPO Less coverage for treatment provided by non-ppo physicians; As mentioned previously, there is a strong financial incentive to use PPO network physicians. For example, members may receive 90% reimbursement for care obtained from network physicians but only 60% for treatment provided by nonnetwork physicians. Thus, if your longtime family doctor is outside of the PPO network, you may choose to continue seeing her, but it will cost you more.

12 Medicaid What is Medicaid? Medicaid is a health insurance program for people with low income. It was created in 1965 as a joint federal-state program to provide medical assistance to aged, disabled, or blind individuals (or to needy, dependent children) who could not otherwise afford the necessary medical care. Who administers Medicaid? Each state administers its own Medicaid programs based on broad federal guidelines and regulations. Within these guidelines, each state (1) determines its own eligibility requirements (2) prescribes the amount, duration, and types of services (3) chooses the rate of reimbursement for services (4) oversees its own program.

13 Medicare Medicare is a federal program that provides health insurance to retired individuals, regardless of their medical condition.

14 What does Medicare cover? Medicare Part A (hospital insurance) Generally known as hospital insurance, Part A covers services associated with inpatient hospital care (i.e., the costs associated with an overnight stay in a hospital, skilled nursing facility, or psychiatric hospital, such as charges for the hospital room, meals, and nursing services). Part A also covers hospice care and home health care. Medicare Part B (medical insurance) Generally known as medical insurance, Part B covers other medical care. Physician care--whether it was received while you were an inpatient at a hospital, at a doctor's office, or as an outpatient at a hospital or other health-care facility--is covered under Part B. Also covered are laboratory tests, physical therapy or rehabilitation services, and ambulance service. Medicare Part C (Medicare+Choice) The 1997 Balanced Budget Act expanded the kinds of private health-care plans that may offer Medicare benefits to include managed care plans, medical savings accounts, and private fee-for-service plans. The new Medicare Part C programs are in addition to the fee-for-service options available under Medicare Parts A and B.