Health Insurance |Ch 11

ACA Affordable Care Act

makes health insurance easier to understand and a bit more affordable

• Now only 5% of Americans have health insurance

some states have tax penalty

can’t be denied coverage because of pre-existing conditions

• used to not be able to switch jobs bc new job may not cover care

men and women must be charged the same rates and premiums

• women used to be charged a lot more

free preventative care and annual check-ups

no limits on maximum payouts

• e.g. reach your maximum only 3 years into chemo when you needed it for 5 years

children can remain on parent’s plan until 26

provides subsidies to make plans more addorable

can go to something called the ‘marketplace’ where you have other options of care (health care exchanges)

• bronze

  • you pay 40%

  • good for if you want to protect yourself from worst case

  • may have high cost if you do need care

  • deduc

• silver

  • You pay 30%

  • moderate cost when u need care

  • may qualify for a cost-sharing reduction

    • premium is lowered but you get it back in taxes

• gold

  • you pay 20%

  • deductible is even lower

  • plan that TX has for employees

• platinum

  • you pay 10%

  • lower deductible

  • highest premium

10 essential benefits of health care

1. ambulatory patient services, such as doctor’s visits and outpatient services (anything where you can walk in and walk out)

2. emergency services

3. hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative services and devices

   • if you tear a muscle or something like that

8. Laboratory Services

   • x-rays and blood work

9. Preventative and wellness services and chronic disease management

   • diabetes, vaccines, etc.

10. pediatric services including oral and vision care

Types of policies (slide 10)

Traditional Health Insurance

HMO

• health maintenance organization (plan)

• lower premium

• low or no deductible

• usually required to select a PCP

• required to get a referral to see a specialist

PPO

• preferred provider Organization (plan)

• higher premiums (more flexible)

• higher deductible

FSA vs. HSA

• HSA can only be used with a High Deductible Health Plans (HDHP)

• FSA can be used with several different kinds of plans

  • pick amount at beginning of year

  • taken in equal installments each month

  • no taxes paid on it

• dependent care FSAS

  • daycare, elderly, or ADA individuals

  • only custodial

  • not prefunded

• Limited FSA

  • given if you also have an HSA

  • used for dental and vision only

co-payments

• anything above it, the insurance pays

• for emergnecies and bigger costs, the % kicks in…you pay 20, they pay 80, but also the deductible will be there

out of pocket maximum

• if you reach this maximum with the deductible, co-pay, and co-insurance, the insurnace then covers 100%

Open enrollment

• when you change jobs, get married, adoption, divorce, newborn, or beginning of a new year (january or june/july)

long term care insurance

• reimburses costs for lomg-term care

  • not covered by medical insurance

• based on degree of impairment

• can be expensive

• start it by around 50

disability income insurance

• privately or through an employer

• good for dangerous jobs or as you get older

• pays a daily rate

short term disability (STD)

• income replacement (for what you can’t make)

• state: 60%, up to 850 per week

• doesn’t start until you use all of your sick leave + a week

  • lasts 22 weeks max or a month for a pre-existing condition

Long term disability (LTD)

Social Security Disability Insurance

• at least 40 social security credits

  • 4 credits per yaer, so 10 yrs of work

• if someone is not able to work due to disability

not having health insurance is the #1 cause of personal bankruptcy