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Chapter 11: Health Care Planning

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Explain the major provisions of health care plans and insurance policies. ... Health Care Providers. Individual. Group. Lower rates. Employee fringe ... – PowerPoint PPT presentation

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Title: Chapter 11: Health Care Planning


1
Chapter 11 Health Care Planning
2
Objectives
  • Identify the major sources of health care plans.
  • Describe the major types of coverage provided by
    health care plans.

3
Objectives
  • Explain the major provisions of health care plans
    and insurance policies.
  • Describe the purpose and major features of
    disability income insurance.

4
How Can You Reduce Your Personal Health Care
Costs?
  • Stay well - focus on prevention
  • eat a balanced diet and keep your weight under
    control
  • avoid smoking and dont drink to excess
  • get enough rest, relaxation, and exercise
  • drive carefully and look for accident and fire
    hazards in your home

5
Health Insurance and Financial Planning
  • Protection against financialloss due to illness
    or injury.
  • Part of your overall risk management plan to
    safeguard your familys economic security
  • medical expense insurance
  • disability income insurance to protect your most
    valuable asset - your ability to earn an income

6
Health Care Planning
FOUR LOSS TYPES
  • Direct medical care
  • Recuperative care
  • Rehabilitation
  • Replacement of income

7
Health Care Providers
  • Individual
  • Group
  • Lower rates
  • Employee fringe
  • Coverage for existing health problems

8
Health Insurance and Financial Planning
(continued)
  • Group plans comprise more than 85 of all health
    insurance issued
  • Most group plans are sponsored by employers, with
    the employer paying most or all of the cost
  • Group plans can be supplemented with individual
    plans
  • Following divorce, a former spouse can remain
    covered for three years, but the premiums can be
    as high as 4,000 a year

9
Health Care Providers
  • Private insurance companies
  • Managed care plans
  • Preferred provider
  • Health maintenance

10
Health Care Providers
  • Government plans
  • Medicare
  • Medicaid

11
Health Care Coverages
  • Hospital
  • Surgical
  • Medical expense
  • Major medical expense
  • Comprehensive health
  • Dental expense and vision care

12
A Good Health Insurance Plan Should..
  • Provide quality care at a reasonable cost
  • Offer basic coverage for doctor and hospital
    bills
  • Cover 120 days hospital room and board
  • Provide at least 1,000,000 lifetime maximum per
    person
  • Pay 80 of out-of-hospital expenses after the
    deductible is met
  • Have no unreasonable exclusions
  • Limit out-of-pocket expenses

13
Types of Health Care Coverages
  • Hospital
  • hospital room, operating room, lab tests,
    X-rays, medicine
  • Hospital indemnity
  • pays a fixed amount for each day in hospital.
    Best for people in high risk groups
  • Surgical
  • surgeon's fee
  • Physician
  • office visits, lab tests and X-rays

14
Types of Health Care Coverages
(continued)
  • Major medical
  • covers expenses for a long term injury or
    illness
  • Comprehensive major medical
  • low deductible offered without a separate, basic
    plan
  • Dread disease
  • focuses on unrealistic fears, and only pays out
    for very specific conditions. Often sold by
    people working on commission.

15
Types of Health Care Coverages
(continued)
  • Dental
  • group coverage for exams, cleaning, x-rays,
    fillings, oral surgery
  • Vision care
  • some group plans include exams and glasses
  • Long term care
  • fastest growing coverage, especially for women

16
Health Care Coverages
  • Medicare supplement (Medigap)
  • Long-term care
  • Accident and dread disease

17
1996, Teacher's Insurance and Annuity Association
18
Making Sense of Health Benefits
GENERAL TERMS AND PROVISIONS
  • Definitions
  • Who is covered
  • Time period

19
Making Sense of Health Benefits
PAYMENT LIMITATIONS
  • Policy Limits
  • Deductibles and copayments
  • Coinsurance
  • Coordination of benefits

20
Making Sense of Health Benefits
COVERAGE LIMITATIONS
  • Based on timing of loss
  • General exclusions
  • Maternity benefits

21
Disability Income Insurance
  • Disability income insurance replaces a portion of
    the income lost when you cannot work because of
    illness or injury.
  • The chances of becoming disabled for at least
    three months are seven times greater than the
    chances of death!

22
Disability Income Insurance
  • Level of need
  • Important policy provisions
  • Elimination period
  • Benefit period
  • Degree of disability

23
Disability Income Insurance
  • Important policy provisions (continued)
  • Residual clause
  • Social Security rider
  • Cost-of-living adjustments

24
How Long YourMoney Will Last
25
Trade-Offs in Choosing a Policy
  • Reimbursement versus indemnity
  • Inside limits versus aggregate limits
  • Deductibles and coinsurance
  • Out-of-pocket limit, or stop-loss
  • Benefits based on reasonable and customary charges

26
How to Choose an HMO
  • Consider the following factors
  • accessibility
  • convenient office hours
  • alternative physicians
  • second opinions
  • type of coverage
  • appeal procedures
  • price
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