Basics of Health Insurance

To help offset the cost of medical care Protection against financial losses resulting

from illness or injury

Covers services and procedures that are considered medically necessary

Covers preventive care

The Purpose:

Elective Procedures such as:

Breast Augmentation Abdominoplasty Blepharoplasty Rhinoplasty Botox Other elective, non-medically necessary

procedures

DOES NOT COVER

Health Insurance for sickness or injury Coverage for accidents Disability Hospitalization Accidental death Dismemberment

Different types of Insurance

The insured is also known as the policy- holder

Can be an individual, group or employer A set amount is paid monthly to the

Insurance company, this is called a premium

The insured receives benefits, (payments for medical coverage) and is known as the beneficiary

A dependent is the spouse or child of the insured who is covered under the policy

Here’s the lowdown-

The Medical Assistant may need to call the Patient’s Insurance Compnay to verify the Eligibility of the patient’s coverage

Or to obtain an Authorization for an upcoming medical procedure

And More…

A carrier is the Insurance Company who “carries” the coverage

According to the policy the patient pays a portion of the amount owed-

This is called a -Deductible

Many plans now require a co-payment from the patient at the time of their appointment. $10-$25.00

Insurance Companies

Many large groups of people are covered by government plans.

MEDICARE part B Is for patients 65 and

over.

Military dependents are covered by TRICARE

CHAMPVA is coverage for surviving spouses, children

Government Plans

MEDICAID is coverage for individuals who cannot pay for medical coverage themselves

Estab. 1965

Medical Savings Accounts (MSA’s)

A type of self insurance where the insured can buy health insurance and make tax free deposits to an MSA

Other:

Types of Plan Benefits Hospitalization

Basic/Major Medical

Vision Dental Long term care

-Covers all or part of the room, medicines, care, surgery, etc.,

-Inpatient/OutpatientRadiology, laboratory,

Disability Insurance

Disability- weekly or monthly cash payments are provided to employee/policy holders who become unable to work as a result of accident or illness

Long term care- chronically ill, disabled or mentally ill

Some Insurance companies agree to pay on the basis of all or a part of the physician’s UCR fee.

Usual Customary Reasonable

Who decides how much to pay?

Managed care is an umbrella term for all healthcare plans that provide healthcare in return for preset, scheduled payments,

To coordinate healthcare through a group of physicians & hospitals

Managed Care

Health Maintenance Organization-

Provide comprehensive healthcare to an enrolled group for a fixed periodic payment

Advantages: 1. costs are

contained 2. fees are set 3. covers most

preventive care 4. less out of

pocket for patients

HMO’s

Disadvantages: 1. Medical care

access is limited 2. choice of

physician is limited 3. more paperwork 4. Pre-Auth

required

All healthcare may be managed at one facility

HMO’s

Other types of companies…

EPO PPO

EPO Exclusive Provider Organization “Exclusive” because employers agree to one plan

PPO Preferred Provider Organization

“Preferred” because it is based on fee for service, with preferred physicians

Co-pay/80-20%

Insurance Companies

Private plansGovernment plans

Blue Cross/Blue Shield Cigna Aetna Kaiser Permanente Humana United Healthcare Coventry Assurant

Medicare Medicaid Tricare ChampVa