Foundation Standard 33.15 Discuss common methods of payment for healthcare.

Health insurance plans help pay for the costs of health care.

50/308 million Americans are uninsured (without health insurance)

15% of gross national product ($ spent on goods and services in USA) is on health care.

What can happen to individuals and families if they do not have health insurance?

Plans are offered by thousands of different insurance agencies.

For example, Blue Cross Blue Shield Insurance terms:

Premium – cost you pay each month for insurance policy

Deductible – amount patient pays for medical service before insurance company pays

Co-insurance – % of expense shared by patient (i.e. 10% for dental)

Co-payment – specific amount patient pays for a particular service (i.e. $10/$20 for Rx)

Employer-sponsored Coverage(Group insurance) = Employer assisted health insurance coverage for employees.

Employer often pays part of premium. Private insurance = purchased by an

individual (Sometimes called a 3rd party payer)

What is supplemental insurance?

An effort to provide quality care at lowest possible cost.

A 2nd opinion or pre-approval is often required for special care.

Focus is on preventive measures – screening, education, vaccinations, etc.

Network of contracted providers (doctors, therapists, hospitals, etc.) provide care at most reasonable cost.

HMOs & PPOs are main providers of managed care.

Monthly fee (premium) paid for membership

Premium paid by employer or individualFocus on preventive health careParticipants required to use only HMO-

affiliated healthcare providers (can’t go outside of network)

Need a primary care physician established (especially if need referral to specialist)

Premium paid for membershipPPO contracts with health

providers to provide health care at reduced rates.

PPOs usually require a deductible and co-payment

If non-affiliated provider used, PPO may require co-payments

Can usually see a specialist without approval (if in network)

Provides health care for: Individuals over the age of 65 Person with disability for >2 years

Three types of coverage: Type A for hospital insurance Type B for medical insurance Type D for pharmaceutical expenses

Individuals pay a premium and deductible for Type B coverage

Medicare only pays 80% of services

Jointly funded by federal and state government, but operated by individual states

States establish eligibility standards, payment rates, etc.

Usually pays healthcare for: Individuals with low incomes Children who qualify for public assistance Individuals who are physically disabled or

blind

Govt effort to control costs for Medicare & Medicaid

Patients with certain dx classified in 1 payment group

Limit placed on cost of careAgency only gets the set amount, so

makes every effort to stay within the expense limit allowed

Health insurance plan for workers injured on the job

Administered at state levelPayments made by

employers & statePlan also reimburses for

wages lost because of on-the-job injury.

U.S. Government health insurance plan for military personnel.

Provides civilian health care for active duty military members and their families, survivors of military personnel, and veterans

Consolidated Omnibus Budget Reconciliation Act of 1985

Requires employers with group health plans to offer employees to continue temporarily health care coverage if their employment ceases due to termination or layoff