Health Insurance 101 - PowerPoint Presentation

Slide1

Health Insurance 101Slide2

What is Health Insurance?

Health

insurance is a contract between a consumer and an insurance company.Health coverage helps people pay for medical costs and protects them from very high expenses. With a plan, insurance companies and consumers both pay for health care.

Health Insurance 101Slide3

Health Insurance TermsThe

premium

is the amount paid for health coverage. Consumers and/or their employers usually pay it monthly, quarterly, or yearly.Premiums vary depending on:health care coverage anddeductibles, copayments and coinsurance.Health Insurance 101Slide4

Health Insurance Terms (cont.)

The

deductible is the amount consumers owe for health care services before the health insurance or plan begins to pay.Generally, a plan will have two deductibles: in-network and out-of-network deductiblesHealth Insurance 101Slide5

Deductible ExaminedConsumer has a $1,200 deductible

Consumer

has a medical procedure and is charged $1,200Insurance company only allows $1,000 for procedureInsurance company pays nothing, consumer pays $1,000 and has $200 of deductible amount leftHealth Insurance 101Slide6

Health Insurance Terms (cont.

)

The copayment (or copay) is a fixed amount (e.g. $15) consumers pay for a covered health care service, usually at the time of service. Copays vary by the type of covered service, such as seeing a doctor, filling a prescription, or going to the emergency room. Co-pays

may be lower

for services delivered by primary care doctors

than

by specialists.

Copays

for

in-network

providers are typically lower than for out-of-network providers.

Health Insurance 101Slide7

Health Insurance Terms (cont.)

Coinsurance

is the percent of the cost of covered health care services paid by consumers. The consumer pays coinsurance plus any deductibles and copayments that are owed. Health Insurance 101Slide8

Coinsurance ExaminedConsumer

has met the deductible

Consumer has a 80/20 coinsurance requirementConsumer has $100 in covered medical expensesInsurance company pays $80 and consumer pays $20.Health Insurance 101Slide9

Health Insurance Terms (cont.

)

The coinsurance cap or stop loss provision places a cap on the amount of money the consumer pays for covered services after the deductible. Coinsurance caps do not apply to copayments.Health Insurance 101Slide10

Health Insurance Terms (cont.)

Claim

is a request for payment that a consumer or healthcare provider submits to the health insurance company for items or services rendered.Health Insurance 101Slide11

Health Insurance Terms (cont.

)

Allowed amount is maximum amount allowed to be paid for covered health services by a health insurance company. May also be called “eligible expense,” “payment allowance,” or “negotiated rate.”If a provider charges more than allowed amount, the consumer usually doesn’t have to pay the difference (if using a participating provider).Health Insurance 101Slide12

Health Insurance Terms (cont.

)

Balance billing: when the provider bills the consumer for the difference between the provider’s charge and the amount allowed by the health plan. Health Insurance 101Slide13

Balance Billing ExaminedIf

the provider charges $100 and the allowed amount is $70, the provider may bill the consumer for the remaining $30

.Some providers may not balance bill consumers for covered services. This is the case with a preferred or participating provider. It’s important to understand a plan’s provider network and whether it costs more to see certain providers.Health Insurance 101Slide14

Health Insurance 101

How to Get Insurance

Health insurance inside the marketplace – Consumers can enroll in health coverage through the marketplace beginning on November 1, 2015.

Health insurance outside the marketplace

–

Consumers

can obtain health coverage through a health insurance company that sells insurance outside of the marketplace.

Job-based insurance

–

Consumers

who are currently employed may be able to purchase health coverage through their employer, called employer-sponsored or job-based.

If

consumers lose or quit their job, they may extend the job-based health insurance through a program called Consolidated Omnibus Budget Reconciliation Act (COBRA).

Instead

of choosing COBRA, consumers may also role in coverage through the

marketplace instead.

Insurance under a parent’s policy

–

Younger

adults ( up to 26 years old) are eligible to enroll in health coverage under their parents health insurance plans if those plans cover dependents.Slide15

Health Insurance 101

Additional Health

Coverage OptionsMedicare – Medicare is the federal health insurance program for

people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease

(permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

.

Medicaid

–

a joint federal and state administered health insurance program for

low income families and children, pregnant women, the elderly, people with disabilities

, and in some states, other adults.

Children’s health insurance program (CHIP)

-

a program jointly funded by state and federal government that provides

health coverage to low income children

and, in some states, pregnant women, and families who earn too much to qualify for Medicaid,

but they

cannot afford private health insurance.

TRICARE

–

is

the Department of Defense (DoD)

healthcare program available to eligible members and their families of the seven uniform services

: the US Army, US Navy, US Air Force, US Marine Corps, US Coast Guard, commissioned Corps of the US Public health service, and the National Oceanic and Atmospheric Administration

.

Veteran affairs (VA) health benefits

–

the Department of Veterans Affairs (VA) administers a variety of benefits and services that provide financial and other forms of assistance to

service members, veterans, their dependents and survivors.

As part of these benefits and services, the VA provides health coverage for eligible veterans who served in the US military.Slide16

Health Insurance 101

Different Types of Health Insurance PlansSlide17

Health Insurance 101

Types of Health Insurance Plans

(cont.)Preferred Provider Organization (PPO) - a type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. Consumers pay less if they use providers that belong to the plans network.

Consumers can visit doctors, hospitals, and providers outside of the network at an additional cost.

Referrals

are often not needed to see specialists.

In

exchange for greater access to

providers,

premiums are generally higher in a PPO than in an HMO.Slide18

Health Insurance 101

Types of Health Insurance Plans

(cont.)Point of Service (POS) Plan – a type of plan in which consumers pay less if they use doctors, hospitals, and other healthcare providers that belong to the plan’s network.

With

this type of plan, a

consumer may go to out-of-network providers at a higher cost

.

POS

plans may also require consumers to get a referral

from the primary care doctor in order to see a

specialist.Slide19

Health Insurance 101

Types of Health Insurance Plans

(cont.)Health Maintenance Organization (HMO) - a type of health insurance plan that usually limits coverage to care from in-network doctors who work for or contract with the HMO.

It

generally will not cover out-of-network care except in an emergency

.

An

HMO may require consumers to live or work in its service area to be eligible for coverage.

In

exchange for the limited access to providers, premiums are typically lower in an HMO than in other types of plans.Slide20

Health Insurance 101

Types of Health Insurance Plans

(cont.)High Deductible Health Plan (HDHP) - a plan that features higher deductibles than traditional insurance plans in exchange for lower monthly premiums

.

HDHPs

can be combined with a health savings account (HSA) or a flexible spending account (FSA). Slide21

Health Insurance 101

Types of Health Insurance Plans

(cont.)Catastrophic Health Plan – a type of plan that is designed to provide emergency service and to protect consumers from unexpected medical costs, but has limits on regular doctor visits.

The

premium amount that a consumer pays each month for health care is generally lower than other types of

plans.

Out

-of-pocket cost for deductibles, copayments, and coinsurance

are

generally

higher than other plans.Slide22

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