Health
Insurance Plans
Intro to Health Science
Unit One Lesson 5
Diversified Health Occupations
pages
Objective
 Compare
basic principles of at least four
different health insurance plans
Introduction
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Cost of healthcare is a major concern of
everyone who needs health services
Health care costs are increasing much faster
than other costs of living
Most people rely on health insurance plans to
pay for health care costs
Without insurance the cost of an illness can
become a financial disaster
Most people rely on health insurance plans to
pay for health care costs, and there are many
different types of these plans
Health Insurance Plans
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Offered by thousands of insurance agencies
Popular example Blue Cross-Blue Shield
Premium or payment made to insurance
company
If insured individual has expenses covered by
the plan, the insurance company pays for the
services
Amount of payment and services covered
vary from plan to plan
Insurance Terminology
Deductible
CoPayment
CoInsurance
• Amount that must be paid by insured individual
for medical services
• Must be paid before the policy begins to pay
• Specific amount of money patient pays for a
particular service
• Example: $10 each physician visit regardless of
total cost of visit
• requires that specific percentages of expenses
are shared by individual and company
• 80-20%: insurance pays 80% you pay 20%
• 50-50%: insurance pays 50%, you pay 50%
Health Insurance Plans
 Many
individuals have insurance from
place of employment
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At times employer pays entire cost of plan
Other times, cost is shared by employer and
employee
 Private
policies can also be purchased by
individuals
Health Insurance Plans
HMO
US
Government
Plans
PPO
Workman’s
Compensation
Medicare
Medicaid
Health Maintenance
Organizations (HMOs)
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Special type of insurance
plan
Monthly fee or premium
paid for membership and
fee stays the same
regardless of amount of
health care used
Premium can be paid by
employer and/or individual
Most pay for total health
care including routine
exams and preventative
type of care, not usually
covered under other
insurance plans
HMO’s
 Advantages
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Provides readily
access to health
care
Early detection
and treatment
Individual
maintains better
state of health
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Disadvantages
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Individual can only
use certain HMO
affiliates (doctors,
labs, hospitals)
If individual chooses
nonaffiliated health
care provider, the
individual must pay
for the care
Preferred Provider
Organizations (PPOs)
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Usually provided by
large industry or
company
Industry/company
contracts with certain
health care agencies
Employee restricted to
using the specific
health care agencies
Industry/company can
provide health care at
lower rates
Medicare
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Federal government
heath care plan
Provides coverage
to the following
individuals:
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Over age 65
Persons with
disability who have
had social security
benefits for at least
two years
Medicare Continued
Type A
Type B
* Covers hospital services
* Coverage for doctor's
services, outpatient
treatments, therapy, and
other health care
* Covers care by extended
care facility or home
health care after
hospitalization
* Individual pays premium
for this coverage
* 80-20% co insurance
Medicaid
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Medical assistance
program operated by
individual states
Benefits and individuals
covered vary from state
to state
Usually covers
individuals with low
incomes, children who
qualify or public
assistance, and
individuals who are
physically disabled or
blind.
Workers Compensation
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Provides treatment
for workers injured on
the job
Administered by the
state
Payments made by
employers and the
state
Provides payment for
health care and lost
wages
United States
Government Plans
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Provide health care for
all military personnel
TRICARE(formally
CHAMPUS)
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Care for ALL active
duty members and
families
Care for survivors of
military personnel and
retired members of
the armed forces
Veterans
Administration
Managed Care
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Developed because of
rising cost of health care
Employers and insurance
companies want to see
that money is spent
efficiently rather than
wastefully
Principle is that all health
care provided to patient
must have a purpose
Second opinion or
verification of need is
frequently required
Managed Care Continued
 Every
effort is made to provide
preventative care and early diagnosis of
disease
 Usually provides routine physical exams,
well baby care, immunizations, and
wellness education to promote good
nutrition, exercise, weight control, and
healthy living practices
Managed Care Continued
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Employers and Insurance companies create a
network of doctors, specialists, therapists, and health
care facilities that will provide care at the most
reasonable cost
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HMOs and PPOs are main providers
Private insurance companies set up health care networks
Networks compete for consumer dollar and are required
to provide quality care at lowest possible cost
Health care consumer receives quality care at most
reasonable cost, but is restricted in choice of health
care providers
Review
 Health
plans
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insurance
DO NOT solve all
problems of health
care cost
DO help many
people pay for all
or part of cost
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is important to
understand
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what your plan
covers
Co insurance and
other restrictions
your plan may
have
Check for Understanding
What is an
advantage of
HMOs?
What type of plan
restricts individuals
to the use of certain
health care
facilities?
Who pays the
premium for private
health care
insurance?
What plan provides
insurance to
individuals over 65
years of age ?
What does a
75-25 percent
co insurance mean?