Health Insurance

Health Insurance Explained

Pay your premium every month
- like a cable subscription
- shared healthcare piggy bank
  - chip in each month so the money is there when you need
- Medicaid people don’t pay premium
- HIX
  - Tax credit might cover your premium
Insurance helps, but doesn’t cover everything
- Copay
  - How much you pay after insurance
- Coinsurance
  - % of your visit you have to pay
- Deductible
  - How much comes out of your own pocket before insurance helps
  - Might only apply to some types of care
- Out of Pocket Maximum
  - The most you’ll have to pay in one year
  - Insurance pays anything beyond the max
- Formulary
  - List of drugs your plan pays for
- Provider Network
  - List of doctors and hospitals connected to your plan
  - Out of pocket limit does not apply out of network
HMOs
- no coverage
PPOs
- Coverage oon
Sometimes it can be difficult to stay in network
- Negotiate and appeal with insurance and provider

What are MCOs and Why do they Matter?

MCOS
- MCOs are healthcare delivery systems designed to control cost and maintain quality and access
  - Build provider networks
  - Negotiate rates
- HMOs, PPOs, POSs, EPOs
  - Guide care delivery
  - Limit unnecessary procedures
  - Keep patients in network
Managed Care emerged in the 70s
- Address rising costs
- Coordinate, and structure care delivery