Health Insurance Notes

Health insurance is a form of protection that eases the financial burden of medical expenses.
It typically includes a deductible.

Most popular form of coverage.
Employer-provided.
Fairly low-cost.
Can be offered through companies with a minimum of ten employees.
Benefits:
- Lower premiums.
- Possible federal tax breaks.
Costs:
- Lacking choices in policies.
- Employees preferring individual insurance.

Available for purchase directly from the insurance company.
Usually offers plans for individuals or families.
Can be adapted to meet specific needs.
Varies in price, coverage, and length.
Benefits:
- Ability to choose a preferred doctor.
- Allowing shorter wait times
- Offering improved facilities
Costs:
- Requiring higher premiums than most public health insurance.
- Creating inequality.
- Limiting coverage of certain medical services.

Allows individuals to keep a former employer’s group coverage for a set period.
Protects against the loss of insurance due solely to being temporarily unemployed.
Benefits:
- Protection to those with pre-existing health conditions.
- Insurance to those transitioning between jobs.
Costs:
- Limiting the time frame of coverage.
- Requiring higher costs.

Medicare:
- Federally funded health insurance program available mainly to people over 65 and to people with certain disabilities.
Medicaid:
- Medical assistance program offered to certain low-income individuals and families.
- Administered by states, but financed by a combination of state and federal funds.
Benefits:
- Improving public health.
- Saving lives.
- Making medical services affordable for those with a low socioeconomic status.
Costs:
- Increasing the U.S. debt and deficit.
- Increasing the wait time for medical services.
- Causing people to overuse health care resources.

Includes hospital expense coverage, surgical expense coverage, and physician expense coverage.
Examples:
- Room and board during hospital stay.
- Anesthesia.
- Laboratory fees.
- X-rays.
- Surgeon fees.
- Routine doctor visits.

Pay benefits when the policyholder is hospitalized.
Do not directly cover medical costs.
Pay policyholders in cash, which can be spent on medical or non-medical expenses.
Are often used as a supplement to basic health or major medical policies.

Provides reimbursement for the expenses of dental services and supplies.
Encourages preventative dental care.
Normally provides for oral examinations, fillings, extractions, oral surgery, braces, and dentures.
May have a deductible.

Provides coverage for the expense of daily help when a person becomes extremely ill or disabled and is unable to take care of self.
Is helpful if an individual is required to stay in a nursing home or requires a visiting home nurse.
Benefits:
- Maintaining independence.
- Providing affordable quality care.
- Reducing the financial and psychological stress which a long-term care event may cause a family.
Costs:
- Requiring higher premiums.
- Delivering limited benefits.

Can help avoid financial hardships due to expensive medical care and treatment for cancer.
Cannot be denied to the applier due to preexisting conditions or family history.
Covers most costs of unexpected cancer diagnoses.

Reimbursement pays the policyholder back for actual expenses.
Indemnity provides the policyholder with specified amounts regardless of how much the actual expenses may be.

Internal limits cover only a fixed amount for a certain expense.
Aggregate limits are the maximum dollar amount paid for all benefits in a year.
Example: If a person has $120,000$ worth of claims but his or her annual aggregate limit is $100,000$ , the policyholder will be responsible for the last $20,000$ .

States what percentage of the medical expenses the policyholder must pay in addition to the deductible amount.
Example: If the co-insurance is 90/10, the policyholder pays the deductible plus 10 percent of a medical expense, and the insurance company pays 90 percent.

Caps the amount of money the policyholder must pay for the co-insurance.
Example: If a person’s medical expense is $100,000$ and co-insurance is 90/10, he or she could owe $10,000$ ; but if the out-of-pocket limit is $2,500$ , he or she will only be responsible for the $2,500$ and the deductible, and the insurance company pays all the rest of the costs.

Are health insurance plans which directly employ or contract selected medical professionals to provide health care services.
Requires patients to visit a provider within the HMO network.
Typically requires the policyholder to select a primary care physician to provide the majority of their health care and refer them to a HMO specialist as needed.

Include a network of medical service providers who agree to charge lower cost to enrolled patients than non-network providers.
Is similar to an HMO plan except the patient does not have to choose a primary care physician.
Allow patients to visit any medical provider, but higher co-insurance can apply if the chosen provider is not in the network.
Allow patients to visit any network provider at any time without a referral.

Combine the features of an HMO and PPO plan.
Uses a network of participating physicians and medical professionals contracted to provide services.
Similar to an HMO plan, but patients can also visit providers not in the network by paying a percentage of the charge.
Requires a referral for in-network specialists, but referrals for out-of-network specialists are not required.