1.03 Healthcare Finances. Health Insurance Plans Premium-The periodic amount paid to an insurance company for healthcare or prescription drugs Deductible-Amount

1.031.03Healthcare FinancesHealthcare Finances

Health Insurance PlansHealth Insurance Plans

PremiumPremium-The periodic amount paid to an -The periodic amount paid to an insurance company for healthcare or insurance company for healthcare or prescription drugsprescription drugs

DeductibleDeductible-Amount the patient must pay -Amount the patient must pay before the insurance starts to paybefore the insurance starts to pay

1.03 Understand healthcare agencies, 1.03 Understand healthcare agencies, finances, and trendsfinances, and trends 22

Co-pay-Co-pay-A specific amount paid by the A specific amount paid by the patient for each medical service, such as patient for each medical service, such as $15.00 for each doctor visit or each $15.00 for each doctor visit or each prescription filled.prescription filled.

Co-insuranceCo-insurance-The percentage of the bill -The percentage of the bill for services that the policy holder must for services that the policy holder must pay.pay.


Health Insurance PlansHealth Insurance Plans

1.03 Understand healthcare agencies, 1.03 Understand healthcare agencies, finances, and trendsfinances, and trends

Healthcare FinancesHealthcare Finances

44


Healthcare FinancesHealthcare FinancesGovernmentGovernment

Funded by taxesFunded by taxes

55



MedicareMedicare– Pays 80% of the charges for carePays 80% of the charges for care– Serves patientsServes patients

• Over age 65Over age 65• Who have received social security disability Who have received social security disability

benefits for at least 2 yearsbenefits for at least 2 years• With end stage renal diseaseWith end stage renal disease

66



Medicare Plans Medicare Plans

A – hospital careA – hospital care

B – outpatient medical careB – outpatient medical care

C- advantage planC- advantage plan

D – medicationD – medication

77



Medicare Medicare Plan APlan A– The original Medicare planThe original Medicare plan– Automatically enrolled Automatically enrolled

unless the patient unless the patient specifically enrolls in a specifically enrolls in a Medicare Advantage Plan Medicare Advantage Plan (Part C)(Part C)

– Fee-for serviceFee-for service– Pay a deductible and co-payPay a deductible and co-pay

88



Medicare Medicare Plan APlan A– Hospital insurance at no cost to Hospital insurance at no cost to

most peoplemost people– Coverage includes inpatient careCoverage includes inpatient care

skilled nursing facilitiesskilled nursing facilities

critical access hospitalscritical access hospitals

hospitals hospitals

hospice hospice

home healthhome health

99



Medicare Medicare Plan BPlan B– Pays for necessary medical Pays for necessary medical

services and suppliesservices and supplies– Most people pay a premium for Most people pay a premium for

Plan BPlan B– CoversCovers

outpatient careoutpatient care

doctordoctor’’s servicess services

physical or occupational therapiesphysical or occupational therapies

additional home healthcareadditional home healthcare

1010



Medicare Medicare Plan CPlan C– Combination of Combination of Part APart A and and Part BPart B– Provided through private insurance Provided through private insurance

companies approved by Medicarecompanies approved by Medicare– Option of adding Option of adding Part DPart D– IncludesIncludes

HMOsHMOs

PPOs PPOs

Private fee-for-service plansPrivate fee-for-service plans

Medicare special needsMedicare special needs

1111



Medicare Medicare Plan DPlan D– stand-alone prescription drug stand-alone prescription drug

coveragecoverage– most people pay a premiummost people pay a premium– plans vary and cover different plans vary and cover different

drugsdrugs– can choose the best plan for can choose the best plan for

patientpatient’’s needss needs

1212



Medigap Medigap

– A A privateprivate individual insurance policy that individual insurance policy that pays the difference between the charges pays the difference between the charges for care and the amount Medicare pays.for care and the amount Medicare pays.

1313



MedicaidMedicaid• Provides Provides healthcare for:

• people with low incomes• children who qualify for assistance• people who are disabled or blind

1414



MedicaidMedicaid– Funded by federal Funded by federal

government but government but regulated by regulated by individual state individual state governmentgovernment

– Not all people with Not all people with low income qualifylow income qualify

1515



TRICARETRICARE

Military health planMilitary health plan

Serves:Serves:

Active duty personnel and familyActive duty personnel and family

Survivors of military personnelSurvivors of military personnel

Retired military personnelRetired military personnel

1616



Veterans Health AdministrationVeterans Health Administration

PProvides healthcare services rovides healthcare services

to former military personnelto former military personnel

1717

Health Insurance Plans offered by several Health Insurance Plans offered by several thousand Insurance agencies.thousand Insurance agencies.

Examples: Examples:


Healthcare FinancesHealthcare FinancesPrivatePrivate



Private Insurance– Individual insurance plan, the insured pays the total

amount of the monthly premium

Group insurance plan – the insured individual and their employer share the

amount of the monthly premium

1919



Health Maintenance Organization Health Maintenance Organization (HMO)(HMO)

– care is directed toward prevention of diseasecare is directed toward prevention of disease– patient must see only HMO approved patient must see only HMO approved

providersproviders– pay a monthly fee, no additional charge for pay a monthly fee, no additional charge for

carecare– care from non-HMO provider generally not care from non-HMO provider generally not

coveredcovered

2020



Preferred Provider Organization Preferred Provider Organization (PPO)(PPO)

– Group of doctors and/or hospitals that provide Group of doctors and/or hospitals that provide care to a specific groupcare to a specific group

– PPO provides services to the insured at a PPO provides services to the insured at a reduced ratereduced rate

– Usually require a deductible and a co-payUsually require a deductible and a co-pay– Less coverage for treatment provided by non-Less coverage for treatment provided by non-

PPO providerPPO provider

2121



Indemnity PlanIndemnity Plan

־ Traditional plan with freedom to visit Traditional plan with freedom to visit physician of choicephysician of choice

־ No referral required by insurance companyNo referral required by insurance company־ Pay Pay ““up frontup front””־ Get reimbursed amount allowed by Get reimbursed amount allowed by

insurance policy; amounts may varyinsurance policy; amounts may vary

2222



Out of pocketOut of pocket

CASH

CASH

CASH

CASH

CASH

CASH

CASH

CASH

CASHCASH

2323



WorkersWorkers’’ Compensation Compensation

http://www.comp.state.nc.us

Pays for the healthcare of workers injured on the job

2424

Documents

1.03 Healthcare Finances. Health Insurance Plans Premium-The periodic amount paid to an insurance company for healthcare or prescription drugs Deductible-Amount