Health insurance helps cover medical expenses through either traditional indemnity plans or managed care plans like HMOs and PPOs. Traditional plans allow free choice of doctors but require deductibles and coinsurance, while managed care plans have restricted networks but offer lower copays. Government programs like Medicare and Medicaid provide coverage for specific groups like seniors or those who cannot afford care. Healthcare is delivered through three stages from primary care to specialists to tertiary facilities with specialized services.

1. Health Insurance Healthcare, Careers and Services Unit

2. What is Health Insurance??? It is the cost sharing to help cover medical expenses, hospital fees, etc…

3. Traditional Health Insurance AKA “indemnity insurance” Finding a physician: Your choice of physician Seeing a Specialist: You may see a specialist at anytime or your doctor decides when to send you to one

4. Traditional Health Insurance Hospitalization: Do not need to plan approval for hospitalization or special tests, etc… Payment: Must pay “deductible” in addition to your premium. (usually $200-1000 per family member) before insurance kicks in. Even then you may pay 20% of the bills Other Services: Usually does not cover prescriptions, preventative care (physicals) or immunizations.

5. Managed Care PPO - Preferred Provider Organization (out of network similar to Indemnity) HMO - Health Maintenance Organization Finding a physician: Must use a physician within the plan’s network PCP = Primary Care Physician

6. Managed Care Seeing a Specialist: PCP must authorize or refer you to the specialist. Specialist must also be affiliated with the network. Hospitalization: PCP must get approval from the plan before hospitalization can occur such as for elective procedures

7. Managed Care Payment: “ copay” – fixed rate (usually $10 – 25) paid for each visit out of your pocket. Some HMOs may have no fees. Other Services: Prescription discounts, preventative care (1 free physical every year), immunizations

8. Government Health Programs Medicare Healthcare coverage for ages 65 and older (deducted from paychecks) covers hospital/nursing homes for 100 days additional insurance (supplemental) is needed to cover Dr. appts and other costs (prescriptions, medical supplies, etc…)

9. Government Health Programs Medicaid Assistance programs for all ages who are unable to afford medical care. Covers both hospital and Dr. appts Paid through state and federal taxes FYI – you have to submit your income to qualify

10. Stages of Health Care III. TERTIARY Specialized equipment or treatment needed. Ex. Kidney dialysis children’s hospitals cancer treatment centers burn centers rehab facilities, etc… II. SECONDARY Referral to a specialist I. PRIMARY First contact with a healthcare provider doctor’s office clinic hence - PCP

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