Health Insurance Plans

Health Insurance is a plan that helps the consumer pay for medical costs.

The High Cost of Health Care

We need insurance to help with the rising costs of healthcare.

Emergency Medical Treatment & Active Labor Act

EMTALA (federal law): requires that hospital emergency departments treat emergency condition of all patients regardless of their ability to pay.

Acts To Know

COBRA: Consolidated Omnibus Budget Reconciliation Act (1986) 

- employee can pay to keep group health insurance for 18-36 months after leaving a job or losing health insurance

Patient Protection and Affordable Care Act:

  • 4 Goals

  1. Make affordable health insurance available to more people

  2. Expand Medicaid program to cover all adults with income below 138% Federal Poverty Level (FPL)

  3. Support medical care delivery methods to help lower the cost of health care.

  4. Access to insurance for those with pre-existing condition.

    Terms To Know

    Pre-existing Condition: an illness already present when applying for a new insurance plan

    Tort reform: laws limiting medical malpractice suit payments

    DRGs: Diagnostic Related Groups – Medicare pays a set amount for specific classifications of diagnoses regardless of actual cost

    Premium: amount you pay to belong to a health plan

    Deductible: amount you must pay each year before the health plan beings paying.

    Co-insurance: percent of medical costs a person must pay after meeting deductible

    Max Out of Pocket: the amount you have to pay out of pocket before insurance pays 100%

    Co-pay: set fee paid each time a person receives medical care

    Places to get Health Insurance from

    Group insurance: employer offers plan to workers/share cost of premiums

    Individual insurance: purchase plan directly from insurance company/pay own premiums

    Types of Insurance

    Fee-For-Service

    Can choose any provider, deductible, physicians set their own prices for services, and has gotten too expensive for most people

    Managed Care Planes

    A “network” of providers on the plan, provides incentive to providers t cut costs, costs lower if use network providers, no insurance claim forms, and co-pays.

    HMO: Health Maintenance Organization

    Receive most of care primary care providers (PCP) PCP coordinate health care needs of patients to help control costs, specialists require a referral, will only pay for network providers, & pays 100% for routine and preventative care

    PPO: Preferred Provider Organization

    More flexible than HMO, also more expensive, no referrals for specialists, can use network or non-network providers, pay more for non-network

    Medicare

    Federal, health coverage for age 65 and older and people under 65 if they have end-stage renal disease or Amyotrophic Lateral Sclerosis (ALS)

    plan A- hospital coverage/no premium

    pan B- physician coverage, tests, premium, optional

    plan C- (Medical Advantage) People with Plan A&B can choose to receive all of their health care services through a provider organization (HMO or PPO)

    plan D- prescription drugs

    Medicaid

    Federal, administered by states, covers those under 65 with low income (pregnant women and children, people who receive Supplemental Security Income (SSI) which includes the disabled and the blind, Eligibility and benefits vary by state.

    SCHIP/CHIP

    State Children’s Health Insurance Program-state medical coverage for low income children who do not qualify for Medicaid

    Workers Compensation

    Covers medical care for on-the-job injuries and part of wages lost due to injury. Cost shared by state and employer.

    TRICARE

    federal medical plan for activity duty and retired military personel, their dependents, and survivors

    Patient Protection and Affordable Care Act (Obamacare)

    The law provides many rights and protections that make heath coverage more fair and easy to understand, offers subsidies (premium tax credits) to make insurance more affordable, offers subsidies (premium tax credits) to make insurance more affordable, and allowed people with preexisting health problem to get affordable health insurance.