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Why is health insurance important in PT?
access, cost of treatment, reimbursement for providers, treatment plans/ patient outcomes
What are the top forms of insurance in uS healthcare (highest to lowest)
employer, govt funded, uninsured (out of pocket payment), private insurance
federal program for individuals 65+ and some disabled individuals
medicare
joint federal-state program for low income individuals
medicaid
medical benefits for military service members
VA
how is medicare funded?
revenues, 2.9% payroll tax split b/w employer and employee (if self employed you pay the whole sum), premiums
how is medicaid funded?
federal and state government
how is employer sponsored insurance funded?
payroll contributions (employer and employee), premiums, co-insurance and deductibles
which type of health insurance does not have premiums?
medicaid
Who is eligible for medicare?
those aged 65+, under 65 who receive SSDI
for 24 months (are unable to work), people w/ end stage renal disease or ALS
how long do you have to pay into the social security system to be eligible for premium-free medicare part-A
10 years, this also makes your spouse eligible
does medicare part A include the ER/ urgent care?
no
what does medicare part A cover?
hospital insurance/ inpatient
what does medicare part B cover?
physician services/ outpatient
what does medicare part C cover?
medicare advantage plans
what does medicare part D cover?
Medicare prescription drug plan
Is medicare part B free?
no, $185 a month premium w/ $240 a year deductible
how many medicare beneficiaries also carry supplemental insurance?
more than half
what are medicare advantage plans?
contracts w/ private insurance companies to enroll users and provide coverage for hospital, physician services, and some prescription drugs
what are some cons to medicare advantage plans?
some require referrals for specialists (like PT) and have high co-pays
the eligibility criteria for medicaid is ______ specific
state
who is eligible for medicaid?
adults w’ family income below 150% of poverty level (35,000 for family of 4), children under 19 w/ family income at or below poverty level
who does SCHIP cover?
uninsured children in families w/ incomes at or below 200% poverty level but above medicaid eligibility
who is eligible for employer sponsored health insurance?
full time employees of businesses who offer, dependents (children up to 26)
pros and cons of conventional health insurance plans
more flexibility (no limits on providers) but higher premiums and deductibles
health insurance plan with low premiums but requires referrals and staying on network
HMO (health maintenance organization)
health insurance plan with higher flexibility (in and out of network care) but higher premiums and cost sharing
PPO (preferred provider orginization)
plans that combine elements of HMO and PPO, require referrals for specialists but allow out of network care at a higher cost. Typically have higher deductibles
POS (point of service)
health insurance plan with lower premiums and higher deductibles, often paired with a health savings account
HDHP (high deductible health plan)
how could an HMO insurance plan affect PT care?
limited network can restrict access→ if your practice isn’t in the pts network they can’t go
how could an PPO insurance plan affect PT care?
more flexibility but higher out of pocket costs for patients
how could an HDHP insurance plan affect PT care?
patients may delay care due to higher initial costs
how could an Medicaid insurance plan affect PT care?
fewer restrictions but are subject to state specific limitations
the amount you pay for covered health care services before the insurance plan starts to pay
deductible
the percentage of costs of a covered health care service you pay after deductible (ex: 20%)
coinsurance
a fixed amount you pay for a covered health care service after you’ve paid your deductible
copay
the most you have to spend for covered services in a year, after this amount is reached insurance pays 100% for covered services
out-of-pocket maximum
the max amount an insurance plan will cover for a service
allowed amount
the amount paid to the health insurer each month or period
premium
does medicare or medicaid typically have higher costs associated
medicare
Note 
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