Presentation

on
Health Insurance


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 by
the policy are known as covered services.
Major Medical Insurance Coverage
The following items are often covered by major medical insurance policies:
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
How Health Insurance Works

Many of us cannot afford the risk of not having health coverage. Health
insurance is costly, but the expense from even a minor incident or
illness can easily deplete your savings and can even leave you
financially ruined.
Private health insurance helps people to access health care. The
amount for treatment has to pays by the policyholder up to some
extend and the remaining amount pays by the company.
Health insurance protects consumers from the extreme cost of medical
care. when you become extremely ill, the cost can be financially
overwhelming. Health insurance helps make sure that doesn't happen
to you.

Health Insurance Providers
Both publicly traded and mutual health insurance
companies are licensed health insurers. Blue
Cross and Blue Shield companies are also state
licensed insurers. These programs began as non-
profit organizations under state hospital (Blue
Cross) and state medical (Blue Shield)
organizations. Blue Cross Blue Shield
organizations are now normal commercial health
insurance companies using the Blue Cross Blue
Shield name.

Blue Cross Blue Shield Health
Insurance

BCBS Association is a company composed of many
independent health insurance companies throughout every
state in the nation .
Some companies use only the name Blue Cross
Association and others use only the name Blue Shield
Association, but most independent companies are part of
the Blue Cross Blue Shield Association. Blue Cross and
Blue Shield is Americas oldest and largest independent
health insurer. However, the company actually arose from
two simultaneous, but separate solutions for the health
care of workers organizations.
Types of Health Insurance
Managed Care Health Plan
It is for providing services at low cost.
It mainly focus on prevention and healthy living to avoid
costs.
Currently, nearl y all health insurance plans available to
consumers are managed care insurance plans
By specifying a network of health care providers, managed
care plans permit insurers to influence the treatment
options of their clients. Included in this category are Health
Maintenance Organizations (HMO), Preferred Provider
Organizations (PPO), and Point of Service (POS) plans.

HMO Plans (Health Maintenance
Organizations)

HMO plans are a kind of managed care health insurance plan
HMO plans have a contract with doctors and other health care
providers and they are directly involved in the medical treatment of
their customers.
While HMO plans are generally the cheapest kind of health insurance
coverage available
Most HMO plans require that a primary care physician (PCP) be
designated by recipients. That physician is the gateway to all health
care providers. If a HMO customer tries to visit a medical practitioner
with no a referral from the PCP, the visit or treatment will not be paid
for by the HMO health insurance plan.
HMO plan members pay a monthly premium regardless of their
medical needs.

Advantages of HMO Plans
Preventative Care
HMO plans encourage members to seek medical treatment early and
to have annual checkups. They are focused on wellness and many
HMOs offer information to their members about staying healthy.
Least Expensive Health Insurance
There is usually not a coinsurance requirement with HMO plans.
Instead of a deductible, most HMO plans have small co-payments for
medical services and treatments. So, regardless of your medical
needs, a HMO plan will probably just charge you the monthly premium
and a small co-payment.
No Lifetime Maximum Payout
Unlike other health insurance plans, many HMO policies do not have a
lifetime maximum payout. They will pay for your medical needs as long
as you are a member.
Less complicated billing
Billing systems for HMOs are usually less complex than other
programs, so customers experience less problems.
Disadvantages of HMO Plans
Primary Care Physician Gateway
Specialized medical attention can be more difficult to obtain with an HMO plan. The PCP
is the access to all health care services you can't see a specialist without a referral. This
helps the health insurance company reduce expenses for its HMO members and the
company.
No Coverage for Out-of-Network
HMO insurance will probably not cover a visit to a doctor who is not in the HMO network,
even if there are no network providers in the area.
Strict definitions
The definitions for HMO plans tend to be limited. For example, an emergency room visit may only be
covered if it meets the company's definition of an emergency, which could be surprisingly restrictive.
More difficult to change doctors
Many HMOs discourage you from changing primary care physicians. You may be limited to changing
your primary care doctor once or twice.
Patient quotas
Physicians who participate in HMOs are often required to see a minimum number of patients every
day. This could limit the time your doctor can spend addressing your needs. Some doctors receive a
particular amount from a HMO plan regardless of the number of patients they see, making it
preferable for the doctor to have less appointments.
Tests
Many HMOs require that diagnostic tests be approved before they will be paid for. This could delay
your health care treatment.
PPO Plans (Preferred Provider
Organizations)
PPO plans are very similar to HMO plans. PPO plans provide health
care for their members by contracting with selected hospitals and
doctors. Many PPO programs will cover non-network providers if you
pay a larger co-payment or deductible.
A PPO is a Group of Doctors
Doctors within the PPO network only provide care to a specific group.
The PPO may be sponsored by a health insurance company, an
employer, or a group of employers. The health insurance group trades
the increased patient number for a discounted rate from the health care
provider.
Advantages of PPO Plans
Choice of doctor
PPO networks tend to be much bigger than HMO networks.
If you do see a non-network provider, the majority of PPO
plans will still cover a portion of the cost (it will be less than
they would pay for an in-network provider).
No Primary Care Physician Gateway
You probably will not have to designate a PCP or obtain
referrals before you can visit a specialist if you are a
member of a PPO.
Better Coverage for Chronic Conditions and Non-
traditional Medicine
People with chronic conditions such as back pain,
allergies, and arthritis tend to be more satisfied with PPO
plans. A PPO could also cover non-traditional treatment
such as chiropractic care or acupuncture.
Disadvantages of PPO Plans
More Expensive than HMOs
PPO plans are generally more expensive than
HMO health insurance plans as a result of the
flexibility they offer.
More paperwork
PPOs often require more paperwork than
comparable HMO plans. Customer service and
billing problems are often more frequent with PPO
plans as well.

Point-of-Service (POS) Plans

Point-of-service plans are major health insurance plans
that bring together characteristics of both HMO plans and
PPO plans. They are more flexible than HMOs, but they do
require that you select a primary care physician (PCP). The
PCP must make referrals in order for you to see any other
health care providers.
Point-of-service plans usually charge a small co-payment
to visit an in-network doctor and most do not have a
deductible
Advantages of Point-of-Service
Plans
Choice of Doctor
If you see a non-network provider, most POS plans will still
pay a percentage of the cost (it will be less than they would
pay for an in-network provider unless you obtain a referral
from a PCP).
Small Co-Payment, no Deductible
The majority of point-of-service plans have small co-
payments for medical services and treatments instead of a
deductible. There is normally a deductible and bigger co-
payment for non-network care however.
Disadvantages of Point-of-Service
Plans
Primary Care Physician Gateway
The PCP is the gateway to all health care services. You
won't get complete coverage for a specialist without a
referral. However, unlike an HMO plan, the POS plan will
probably pay a portion of the cost even if you don't obtain a
referral.
More Expensive than HMOs
Point-of-service plans tend to be more expensive than
HMOs, but less expensive than PPOs.
COBRA( Consolidated Omnibus budget
Reconciliation Act) Health Insurance
COBRA is not an insurance plan or company, it is a law. COBRA
health insurance provides retirees, some former employees, spouses,
and dependant children the right to temporary health coverage at group
rates under certain conditions.
Health insurance under COBRA tends to be more expensive for
participants than health insurance provided for active employees since
employers usually pay part of health insurance premiums. However, it
is 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
COBRA health insurance lasts a minimum of 18 months and a
maximum of 29 months. After the original 18 months, it may be
extended if you:
Become disabled within the initial 18 month period
Leave the original job for disability reasons
Or become eligible for Social Security Disability Insurance
within 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 individual
health coverage, or
You become eligible for Medicare
Health Insurance for Seniors
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 failure
requiring 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 been
introduced in Jan 2006 is Medicare Part D, which is a DRUG Insurance
plan. Only the people having either Medicare Part A or B are eligible to
take Plan D.

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 in
rural 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 do
not have to pay a monthly payment called a premium for Part A
because they or a spouse paid Medicare taxes while they were
working.
If you dont automatically get premium-free Part A, you may be able to
buy it if
You (or your spouse) arent entitled to Social Security because you
didnt work or didnt pay enough Medicare taxes while you worked and
you are age 65 or older, or
You are disabled but no longer get premium-free Part A because you
returned to work.
If you have limited income and resources, your state may help you pay
for Part A and/or Part B.
Part B (Medical Insurance):
Helps Pay For:
Doctors' services, outpatient care, and other
medical services that Part A doesn't. Part B
helps pay for these covered medical
services and items when they are medically
necessary. Part B also covers some
preventive services.
Medicaid for seniors
Medicaid may be a good option for seniors who
live on a fixed income and cannot afford to obtain
the health care they need. Additionally, the
Medicaid program can provide nursing home,
adult daycare, and other long term care coverage
to people who meet certain eligibility criteria.
Medicaid beneficiaries do not need Medigap
coverage since Medicaid will pay for their health
care expenses. Individuals within 120% of the
poverty line are eligible for coverage that will pay
their Part B premiums.
Medicare Supplement Insurance

Since Medicare does not cover all health care expenses,
Medicare supplement insurance is sold as supplemental
health insurance for Medicare recipients. There are a
number of gaps in Medicare coverage, so this Medicare
supplement insurance is often known as Medigap.
Required benefits under any Medicare supplement insurance
plan:
65 hospital days beyond Medicare coverage (lifetime
allowance)
Part A Hospital Coinsurance (provides for days 61-90)
Part A Hospital Lifetime Reserve Coinsurance (provides for
days 91-150)
Parts A and B three pint blood deductible
Part B 20% Coinsurance

What is MedicareAdvantage?
MedicareAdvantage is a private managed
care health insurance plan for seniors with
the standard Medicare benefits and some
supplemental benefits. Senior prescription
coverage may be included with these
benefits.
What is MedicareSelect?
MedicareSelect is a Medicare supplement
plan or Medigap policy that is similar to a
PPO.








Dental Insurance & Dental
Discount Plans

Dental Insurance

Dental insurance has premiums, co-payments, and
deductibles.
After the deductible is met, all costs are covered, up to the
annual maximum benefit.
Dental insurance policies are only sold by licensed
professionals.
Dental insurance is 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
Orthodontics (braces, retainers, etc.)
Dental Discount Plans

Dental discount plans are membership based programs with enrollment
fees and monthly charges.
Dental discount plans are unregulated.
Dental discount plans can 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 in
the dental care or dental insurance fields 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 plans can 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 plan at
any time.
Some dental discount plans offer discounts on cosmetic procedures
not covered by dental insurance.

Vision Insurance Coverage

Vision Insurance Coverage
Vision insurance covers care and treatment for your eyes.
These plans often cover annual eye exams, glasses,
contacts, and glaucoma screening. Laser eye surgery is
even covered with some vision plans. Vision Insurance can
be extremely restricted. Some policies just pay for the
annual exam or treatment of eye conditions, not glasses or
contacts.
How Vision Insurance Works?
You may have to pay the doctor yourself and submit a
claim for the vision insurance company to reimburse you
later. Other plans pay the eye care provider directly.
Vision insurance is not a substitute for health insurance. In
fact, most often a medical problem discovered by your eye
doctor (such as a cyst or tumor in your eye) would fall
under your health insurance, not your vision insurance.
Health Insurance Cost
Considerations

Deductibles
You will nearly certainly pay a deductible before the health
insurance plan will chip in for your health care. This is
usually an annual amount, which can range from $100 to
several thousand dollars.
Co-Payments
Co-payments are charged for medical services individually.
For example, a doctor visit might have a $30 co-payment
per visit or a prescription may have a $10 co-payment for
each medication.
Coinsurance
Coinsurance is not part of every health insurance policy,
but it is the percentage you must pay after the deductible is
met. If coinsurance is part of your policy, you might be
responsible for 20% or more of the cost of medical care
(after the deductible).
National Provider Identifier

National Provider Identifier is
A new 10-digit, intelligence-free ID for health care
providers
Issued by the Federal government to individual
providers as well as small and large provider
organizations
One NPI per individual provider; one or more NPIs to
uniquely 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)

Why NPI needed
Eliminate all health plan-specific provider identifiers used in the health
care industry All health plan-specific identifiers (such as Medicares
UPIN, Medicaid provider IDs, private health plan provider IDs) will be
replaced 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 care
providers that transmit administrative transactions electronically
All health care providers are eligible to obtain an NPI Covered health
care providers are required to obtain and use their NPIs