Health Insurance Terms Day 2

To start…let’s review some of your questions and comments from last class.

Health Insurance Part 2
Consumer Health Unit

Today’s Intentions:

• The differentiate between types of insurance programs.

• Understand the different types of insurance by analyzing which health insurance plan available would best fit the students’ needs. 

Most Popular Types/Styles of Plans:

• HMO (Health Maintenance

Organization)

• PPO (Preferred Provider

Organization)

• EPO (Exclusive Provider

Organization)

• Coinsurance
• POS (Point of Service)

• A healthcare provider, like a doctor or hospital, does not have a contract with your insurance plan.

• They are not part of your plan's network

• You will likely pay significantly more for services received from them compared to an in-network provider due to the lack of pre-negotiated rates.

Out of network =

• Uses a doctor, hospital, or other health care provider that has a contract with your health insurance plan. 

• In-network providers are also known as network providers.

In network =

All plans use networks...

HMO

• HMO’s manage patients' health care by reducing unnecessary services. This means that premiums are cheaper than a PPO (your monthly bill).

• Most HMOs require members to select a primary care physician (PCP)

  • Physician acts a gatekeeper to medical services

  • PCP 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 

HMO vs. Out of Network:

• Most HMOs will only pay for medical bills for services your PCP approves through referral

• HMOs typically provide no coverage for care received from non-network physicians 

  • exceptions for emergency care while traveling, etc. 

Multiple Choice

Is this statement true or false?  An HMO has a cheaper premium than a PPO. 

• True

• False

Multiple Choice

Is this statement true or false?  You do not need a referral or permission to see a specialist.  

• True

• False

Multiple Choice

Is this statement true or false? If I go out of network, an HMO will still cover part of the cost of the visit.  

• True

• False

PPO:

• Organization of medical doctors, hospitals and other health care providers (known as a network) 

• Premiums are higher than an HMO

• You do not need a referral to see a specialist. ‘Some’ surgeries or procedures may need to require pre-approval by the insurance company

• Network is contracted with an insurer to provide health care coverage at a reduced rate (substantial discount).  

• Copays and deductibles are way lower with a PPO.

PPO vs. Out of Network:

• PPO’s will reimburse some of your costs if you go out of network: 

  • PPO may reimburse 90% of costs for care received within the network, but only 70% of costs for non-network care 

  • Remember: HMO’s do not cover out of network care

Multiple Choice

Is this statement true or false? A PPO premium is less than a HMO premium.  

• True

• False

Multiple Choice

Is this statement true or false?  You do not need a referral with a PPO to see a specialist.   

• True

• False

Multiple Choice

Is this statement true or false? If you go out of network with a PPO, the insurance company will still pay part of the visit.  

• True

• False

What is coinsurance?

• Instead of paying a fixed amount up front (a copayment), the policyholder must pay a percentage of the total cost.

• 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.

  • Example- member might have to pay 20% of the cost of a surgery, while the health plan pays the other 80%.

• TO ADD TO THE CONFUSION - There are hybrids of HMO/Coinsurance and PPO/Coinsurance!!

What are the 3 main differences between an HMO vs. PPO?

1. Which one is more expensive up front or has higher premiums?

   • PPO

2. Which one do you need a referral?

   • HMO

3. Which one will not cover services that are out of network?

   • HMO

Poll

  Do you know what type of insurance plan you have? 

• Yes! I know the name of the company and type of plan.

• I know the name of the company but not the type of plan.

• I know the type of plan (based off today's notes) but not the company.

• No! I do not know...

Other Types of Insurance or 'Add On's'

• Dental Insurance – required to have if age 18 or younger / helps totally or partially cover dental cleanings and other procedures needed (fillings, root canals, crowns, etc.)

• Vision Insurance – not required to have / helps partially cover eye check-ups, contacts or glasses

• Life Insurance - policy guarantees the insurer pays a sum of money to one or more named beneficiaries when the insured person dies in exchange for premiums paid by the policyholder during their lifetime.

• 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 outside of work; Usually only a percentage of your salary. “Workman’s comp” - provides cash benefits and/or medical care for workers who are injured or become ill as a direct result of their job.

• 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 person or supplemental insurance plan

Medicare =

• health insurance for people with lower incomes 

• Funded by state and federal government

• Eligibility rule vary state to state (combination of income and assets)

Medicaid =

Government Funded Programs:

COBRA  = Consolidated Omnibus Budget Reconciliation Act (1985)

• Lose your job - may continue to pay your insurance premium & maintain coverage

COBRA =

• Women Infants and Children

• Program that helps mothers and children with medical bills:

  • Prenatal care

  • Preventive screenings

  • Immunizations

  • Pay for “proper” food and medicines

WIC =

Government Funded Programs:

CHIP = Children’s Health Insurance Program:

• Uninsured Pennsylvania children and teens that are not eligible for Medicaid have access to affordable, comprehensive health-care coverage. 

• Once enrolled, children are guaranteed 12 months of CHIP coverage unless they no longer meet the basic eligibility requirements. 

• Families must renew their coverage every year in order for the coverage to continue.

• There is no waiting list to enroll in CHIP.

To review: there are 5 government funded and run programs at the state and/or federal level =
1. Medicaid
2. Medicare
3. WIC
4. COBRA
5. CHIP

Open Ended

What is the difference between MEDICARE and MEDICAID insurance?

Open Ended

EXIT TICKET: write the most important thing from today’s lesson.