Protection Of The Consumer

1
Part VI

• Protection Of The Consumer

2
Ch. 24

• Health Insurance

3
Basic Health Insurance

• Includes benefits for hospital, surgery, and
  medical expenses
• The extent of benefits depends on the contract

4
Hospital Benefits

• Benefits associated with the hospital
• Often pays specific amounts for specific number
  of days
• Individual may be responsible for deductible or
  coinsurance

5
Surgical Benefits

• Normally pay the surgeons fees up to a specific
  limit set forth in the contract
• Usually 80 of charges

6
Medical Benefits

• Provides for payment of non-surgical physicians
  fees
• Generally pay for 80 of the bills
• These benefits include
• Prescription drugs
• Laboratory test
• Private nurses
• Other out-of-hospital care

7
Contract Provisions

• An understanding of the following contractual
  terms is useful
• Waiting periods, preexisting illness, conversion
  privileges, coverage in other countries,
  exclusions, dependant coverage, coordination of
  benefits, and cancellation and renewal

8
Types of Plans

• Indemnity compensation for damage, loss, or
  injury
• Provides monetary benefits rather than services
• Managed care
• Responsible for delivering services in addition
  to funding them cost effective care

9
Health Maintenance Organizations(HMOs)

• Health-care systems in which the employers pay a
  premium that entitles them to treatment from
  designated providers

10
Preferred Provider Organizations(PPOs)

• PPOs contract with networks or panels of
  providers who agree to negotiate fee schedules
  that are typically 15 to 20 lower than their
  standard fees
• A patient can go outside their network but must
  pay a higher percentage of the fees

11
Point of Service(POS) Plans

• Subscribers choose a primary physician who
  provides basic care and referrals
• Patients who see nonparticipating providers are
  reimbursed but out-of-pocket expense is higher

12
Medicare

• Federal insurance program created by amendments
  to the Social Security Act
• Provides benefits for people 65 and older and
  certain disabled persons younger than 65

13
Medicare

• Medicare has two parts
• Part A
• Helps pay for inpatient hospital, inpatient care
  in a nursing facility, and hospice care
• Part B
• Helps pay for doctors services and other
  out-of-hospital supplies and services

14
Medicaid

• Federal grant aid program that provides
  comprehensive care and nursing home coverage to
  those who qualify
• Eligibility usually requires a low income and few
  assets

15
Medical Savings Accounts

• Eligibility requires an individual
• to be self employed or employed by a firm of 50
  or fewer employees
• Be covered by an insurance policy with an annual
  deductible between 1500 2250

16
Medical Savings Accounts

• Each year 65 of the deductible can be
  contributed to the account
• The savings can be used for medical expenses
  without penalty
• Savings may be withdrawn without penalty after
  the age of 65

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Questions/Terms

• Basic Health Insurance
• Contract Provisions
• Types of Plans
• Health Maintenance Organizations(HMOs)

18
Questions/Terms

• Preferred Provider Organizations(PPOs)
• Point of Service(POS) Plans
• Medicare
• Medicaid
• Medical Savings Accounts

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Read Ch 25

• Health Care Economics