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.
TOP 10 HEALTH INSURANCE IN THE
PHILIPPINES
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 America’s 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 don’t automatically get premium-free Part A, you may be able to buy it
if
 You (or your spouse) aren’t entitled to Social Security because you didn’t
work or didn’t 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).