ppt on health insurance

5/21/2018 PPT on Health Insurance

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Presentationon

Health Insurance


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Health Insurance

Health Insurance Policies: It is a contract between Policyholder (or client) and health insurance

company.

Insurance to insurance is called Reinsurance. Insurance to reinsurance is called Retro insurance.

Covered services. A list of benefits that are covered by the policy will be provided by the

health insurance company. Benefits could include medication,treatment, testing or other medical care. The benefits are covered bythe policy are known as covered services.


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Major Medical Insurance Coverage

The following items are often covered by major medical insurancepolicies: Lab services X-Rays Diagnostic tests including MRIs and CAT-scans Ambulance services

Radiology Blood (and plasma) Oxygen Intensive care and other hospitalization (including all supplies and services

including surgery) Medication

Nursing services and other medical services (including in-home care) Physicians services (surgical, medical, and diagnostic) Anesthesia Dental treatment for injuries Prosthetics
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How Health Insurance Works

Many of us cannot afford the risk of not having health coverage. Healthinsurance is costly, but the expense from even a minor incident orillness can easily deplete your savings and can even leave youfinancially ruined.

Private health insurance helps people to access health care. Theamount for treatment has to pays by the policyholder up to someextend and the remaining amount pays by the company.

Health insurance protects consumers from the extreme cost of medicalcare. when you become extremely ill, the cost can be financiallyoverwhelming. Health insurance helps make sure that doesn't happen

to you.


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Health Insurance Providers

Both publicly traded and mutual health insurancecompaniesare licensed health insurers. BlueCross and Blue Shield companiesare also statelicensed insurers. These programs began as non-

profit organizations under state hospital (BlueCross) and state medical (Blue Shield)organizations. Blue Cross Blue Shieldorganizations are now normal commercial healthinsurance companiesusing the Blue Cross BlueShieldname.
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Blue Cross Blue Shield Health

Insurance

BCBS Association is a company composed of manyindependent health insurance companies throughout everystate in the nation .

Some companies use only the name Blue CrossAssociation and others use only the name Blue ShieldAssociation, but most independent companies are part ofthe Blue Cross Blue Shield Association. Blue Cross andBlue Shield is Americas oldest and largest independent

health insurer. However, the company actually arose fromtwo simultaneous, but separate solutions for the healthcare of workers organizations.


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Types of Health Insurance


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Managed Care Health Plan

It is for providing services at low cost.

It mainly focus on prevention and healthy living to avoidcosts.

Currently, nearl y all health insurance plans available toconsumers are managed care insurance plans

By specifying a network of health care providers, managedcare planspermit insurers to influence the treatment

options of their clients. Included in this category are HealthMaintenance Organizations (HMO), Preferred ProviderOrganizations (PPO), and Point of Service (POS) plans.
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HMO Plans (Health Maintenance

Organizations) HMO plansare a kind of managed care health insurance plan

HMO planshave a contract with doctors and other health careproviders and they are directly involved in the medical treatment oftheir customers.

While HMO plansare generally the cheapest kind of health insurancecoverage available

Most HMO plansrequire that a primary care physician (PCP) bedesignated by recipients. That physician is the gateway to all healthcare providers. If a HMOcustomer tries to visit a medical practitioner

with no a referral from the PCP, the visit or treatment will not be paidfor by the HMO health insurance plan.

HMO planmembers pay a monthly premium regardless of theirmedical needs.
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Advantages of HMO Plans Preventative CareHMO plansencourage members to seek medical treatment early and

to have annual checkups. They are focused on wellness and manyHMOsoffer information to their members about staying healthy.

Least Expensive Health InsuranceThere is usually not a coinsurance requirement with HMO plans.

Instead of a deductible, most HMO planshave small co-payments formedical services and treatments. So, regardless of your medicalneeds, a HMO planwill probably just charge you the monthly premiumand a small co-payment.

No Lifetime Maximum PayoutUnlike other health insurance plans, many HMO policiesdo not have alifetime maximum payout. They will pay for your medical needs as longas you are a member.

Less complicated billingBilling systems for HMOsare usually less complex than otherprograms, so customers experience less problems.


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Disadvantages of HMO Plans

Primary Care Physician GatewaySpecialized medical attention can be more difficult to obtain with an HMO plan. The PCPis the access to all health care services you can't see a specialist without a referral. Thishelps the health insurance company reduce expenses for its HMOmembers and thecompany.

No Coverage for Out-of-NetworkHMO insurancewill probably not cover a visit to a doctor who is not in the HMOnetwork,even if there are no network providers in the area.

Strict definitionsThe definitions for HMO planstend to be limited. For example, an emergency room visit may only becovered if it meets the company's definition of an emergency, which could be surprisingly restrictive.

More difficult to change doctorsMany HMOsdiscourage you from changing primary care physicians. You may be limited to changingyour primary care doctor once or twice.

Patient quotasPhysicians who participate in HMOsare often required to see a minimum number of patients everyday. This could limit the time your doctor can spend addressing your needs. Some doctors receive a

particular amount from a HMO planregardless of the number of patients they see, making itpreferable for the doctor to have less appointments.

TestsMany HMOsrequire that diagnostic tests be approved before they will be paid for. This could delayyour health care treatment.


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PPO Plans (Preferred ProviderOrganizations)

PPO plansare very similar to HMO plans. PPO plansprovide healthcare for their members by contracting with selected hospitals anddoctors. Many PPO programswill cover non-network providers if youpay a larger co-payment or deductible.

A PPO is a Group of DoctorsDoctors within the PPOnetwork only provide care to a specific group.The PPOmay be sponsored by a health insurance company, anemployer, or a group of employers. The health insurance group tradesthe increased patient number for a discounted rate from the health care

provider.
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Advantages of PPO Plans

Choice of doctorPPOnetworks tend to be much bigger than HMO networks.If you do see a non-network provider, the majority of PPO

planswill still cover a portion of the cost (it will be less thanthey would pay for an in-network provider).

No Primary Care Physician GatewayYou probably will not have to designate a PCP or obtainreferrals before you can visit a specialist if you are amember of a PPO.

Better Coverage for Chronic Conditions and Non-traditional MedicinePeople with chronic conditions such as back pain,allergies, and arthritis tend to be more satisfied with PPO

plans. A PPOcould also cover non-traditional treatmentsuch as chiropractic care or acupuncture.
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Disadvantages of PPO Plans

More Expensive than HMOsPPO plansare generally more expensive thanHMO health insurance plansas a result of the

flexibility they offer. More paperwork

PPOsoften require more paperwork thancomparable HMO plans. Customer service andbilling problems are often more frequent with PPO

plansas well.
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Point-of-Service (POS) Plans

Point-of-service plansare major health insurance plansthat bring together characteristics of both HMO plansandPPO plans. They are more flexible than HMOs, but they dorequire that you select a primary care physician (PCP). ThePCP must make referrals in order for you to see any otherhealth care providers.

Point-of-service plansusually charge a small co-paymentto visit an in-network doctor and most do not have a

deductible
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Advantages of Point-of-Service

Plans Choice of Doctor

If you see a non-network provider, most POS planswill stillpay a percentage of the cost (it will be less than they wouldpay for an in-network provider unless you obtain a referral

from a PCP). Small Co-Payment, no Deductible

The majority ofpoint-of-service planshave small co-payments for medical services and treatments instead of adeductible. There is normally a deductible and bigger co-

payment for non-network care however.


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Disadvantages of Point-of-Service

Plans Primary Care Physician Gateway

The PCP is the gateway to all health care services. Youwon't get complete coverage for a specialist without areferral. However, unlike an HMO plan, the POS planwill

probably pay a portion of the cost even if you don't obtain areferral.

More Expensive than HMOsPoint-of-service planstend to be more expensive thanHMOs, but less expensive than PPOs.
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COBRA( Consolidated Omnibus budget

Reconciliation Act)Health Insurance

COBRA is not an insurance plan or company, it is a law. COBRAhealth insurance provides retirees, some former employees, spouses,and dependant children the right to temporary health coverage at grouprates under certain conditions.

Health insurance under COBRA tends to be more expensive for

participants than health insurance provided for active employees sinceemployers usually pay part of health insurance premiums. However, itis usually less expensive than individual health insurance.

COBRA medical insurance benefits include:

Inpatient and outpatient hospital care

Physician care Surgery and other medical benefits

Prescription drugs

Any other medical benefits such as dental and vision care
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COBRA health insurance lasts a minimum of 18 months and amaximum of 29 months. After the original 18 months, it may beextended if you:

Become disabled within the initial 18 month period Leave the original job for disability reasons

Or become eligible for Social Security Disability Insurancewithin the initial 18 month period

May terminate if: The employer stops plan coverage for all employees, or

You fail to pay the premium on time, or

You obtain coverage through another employer group plan, or

You elect to stop COBRA and replace it with an individualhealth coverage, or

You become eligible for Medicare
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Health Insurance for Seniors
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MEDICARE PLANS

Medicare

Medicare is a Health Insurance Program for

People 65 years of age and older.

Some people with disabilities under age 65.

People with End-Stage Renal Disease (permanent kidney failurerequiring dialysis or a transplant).

Medicare has Two Parts:

Part A (Hospital Insurance) - Most people don't have to pay for Part A.

Part B (Medical Insurance) - Most people pay monthly for Part B.

Above two are the most common plans, but one new plan has beenintroduced in Jan 2006 is Medicare Part D, which is a DRUG Insuranceplan. Only the people having either Medicare Part A or B are eligible totake Plan D.


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Part A (Hospital Insurance)

Helps Pay For: Care in hospitals as an inpatient, critical access hospitals (small

facilities that give limited outpatient and inpatient services to people inrural areas), skilled nursing facilities (not custodial or long-term care),hospice care, and some home health care.

Most people get Part A automatically when they turn age 65. They donot have to pay a monthly payment called a premium for Part Abecause they or a spouse paid Medicare taxes while they wereworking.

If you dont automatically get premium-free Part A, you may be able tobuy it if

You (or your spouse) arent entitled to Social Security because youdidnt work or didnt pay enough Medicare taxes while you worked andyou are age 65 or older, or

You are disabled but no longer get premium-free Part A because youreturned to work.

If you have limited income and resources, your state may help you payfor Part A and/or Part B.


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Part B (Medical Insurance):

Helps Pay For:

Doctors' services, outpatient care, and other

medical services that Part A doesn't. Part Bhelps pay for these covered medicalservices and items when they are medicallynecessary. Part B also covers some

preventive services.


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Medicaid for seniors

Medicaidmay be a good option for seniors wholive on a fixed income and cannot afford to obtainthe health care they need. Additionally, theMedicaidprogram can provide nursing home,adult daycare, and other long term care coverageto people who meet certain eligibility criteria.

Medicaidbeneficiaries do not need Medigap

coveragesince Medicaidwill pay for their healthcare expenses. Individuals within 120% of thepoverty line are eligible for coverage that will paytheir Part B premiums.
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Medicare Supplement Insurance

Since Medicaredoes not cover all health care expenses,Medicare supplement insuranceis sold as supplementalhealth insurance for Medicarerecipients. There are anumber of gaps in Medicarecoverage, so this Medicare

supplement insuranceis often known as Medigap.Required benefits under any Medicare supplement insurance

plan:

65 hospital days beyond Medicarecoverage (lifetimeallowance)

Part A Hospital Coinsurance (provides for days 61-90)

Part A Hospital Lifetime Reserve Coinsurance (provides fordays 91-150)

Parts A and B three pint blood deductible

Part B 20% Coinsurance
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What is MedicareAdvantage?

MedicareAdvantage is a private managedcare health insurance plan for seniors withthe standard Medicarebenefits and some

supplemental benefits. Senior prescriptioncoveragemay be included with thesebenefits.

What is MedicareSelect? MedicareSelect is a Medicare supplement

planor Medigap policythat is similar to a

PPO.
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Dental Insurance & Dental

Discount Plans


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Dental Insurance

Dental insurancehas premiums, co-payments, anddeductibles.

After the deductible is met, all costs are covered, up to theannual maximum benefit.

Dental insurance policiesare only sold by licensedprofessionals. Dental insuranceis regulated by state governments. Typical services covered by dental insurance:

Dental checkups and cleanings every 6 months

X-rays (as needed) Oral surgery, tooth extraction, and root canals Fillings, dentures, crowns, bridges, dentures

(prosthodontics) Treatment of gum diseases and other periodontal

tissues


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Dental Discount Plans

Dental discount plansare membership based programs with enrollmentfees and monthly charges.

Dental discount plansare unregulated. Dental discount planscan charge any amount to provide any services

and switch them at any time.

Salespeople do not need to obtain a license or have any experience inthe dental care or dental insurancefields to offer dental discount plans. With a dental discount plan, you still pay the bills. You just get a lower

price where the discount card is accepted. Network size for dental discount planscan be extremely limited. Be

certain that there are providers in your area and be aware that the

providers may revoke their membership in the dental discount planatany time. Some dental discount plansoffer discounts on cosmetic procedures

not covered by dental insurance.


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Vision Insurance Coverage

Vision Insurance Coverage

Vision insurancecovers care and treatment for your eyes.These plans often cover annual eye exams, glasses,contacts, and glaucoma screening. Laser eye surgery iseven covered with some vision plans. Vision Insurancecanbe extremely restricted. Some policies just pay for the

annual exam or treatment of eye conditions, not glasses orcontacts.

How Vision Insurance Works?

You may have to pay the doctor yourself and submit aclaim for the vision insurancecompany to reimburse you

later. Other plans pay the eye care provider directly. Vision insuranceis not a substitute for health insurance. In

fact, most often a medical problem discovered by your eyedoctor (such as a cyst or tumor in your eye) would fallunder your health insurance, not your vision insurance.

Health Insurance Cost


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Health Insurance Cost

Considerations

Deductibles

You will nearly certainly pay a deductible before the healthinsurance plan will chip in for your health care. This isusually an annual amount, which can range from $100 toseveral thousand dollars.

Co-Payments Co-payments are charged for medical services individually.

For example, a doctor visit might have a $30 co-paymentper visit or a prescription may have a $10 co-payment foreach medication.

Coinsurance Coinsurance is not part of every health insurance policy,

but it is the percentage you must pay after the deductible ismet. If coinsurance is part of your policy, you might beresponsible for 20% or more of the cost of medical care(after the deductible).


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National Provider Identifier

National Provider Identifier is

A new 10-digit, intelligence-free ID for health careproviders

Issued by the Federal government to individual

providers as well as small and large providerorganizations

One NPI per individual provider; one or more NPIs touniquely identify an organizational provider and its

subparts Permanently assigned, and not expected to change

Required to be used in HIPAA standard transactions(e.g., claims, claim payment, eligibility, referrals)


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Why NPI needed

Eliminate all health plan-specific provider identifiers used in the healthcare industryAll health plan-specific identifiers (such as Medicares

UPIN, Medicaid provider IDs, private health plan provider IDs) will bereplaced by NPI Simplify provider billing

Facilitate conducting coordination of benefits

Who is Subject to Comply with the NPI

All covered entities are required to comply with the NPI regulations

Covered entities include health plans, clearinghouses, and health careproviders that transmit administrative transactions electronically

All health care providers are eligible to obtain an NPI Covered healthcare providers are required to obtain and use their NPIs

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