Health Insurance 101
What is Health Insurance?

• Health insurance is a type of
insurance coverage that covers
the cost of an insured individua...
Why Do I Need Health
Insurance?
•As medical care advances, health
care costs also increase. The purpose
of health insuranc...
What Should I Look For?
You many need some help narrowing
your choices in the marketplace.
Consider the following 4criteri...
Common Terms- Subscriber
• Deductible: The amount of money you must pay each year to cover eligible
medical expenses befor...
Common Terms- Subscriber
(cont.)
• Participating Provider: Generally, this term is used in a sense
synonymous with Network...
Common Terms- HCP
• Benefit: The amount payable by the
insurance company to a plan member for
medical costs.
• Benefit yea...
Common Terms- HCP
(cont.)
• Coordination of benefits: A system used in group
health plans to eliminate duplication of bene...
Common Terms- Payer
• Buy and Bill: This is a method of acquisition
where the MD will purchase the medication
wholesale an...
Common Terms- Payer
(cont.)
• Lifetime Max: This is the maximum amount that
your insurance company will pay during your
li...
Wrap-Up/Questions

• When dealing with your HCP or Payer, be clear and concise with all questions
relating to your care an...
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Suzi presentation

  1. 1. Health Insurance 101
  2. 2. What is Health Insurance? • Health insurance is a type of insurance coverage that covers the cost of an insured individual's medical and surgical expenses. • In countries without universal health care coverage, such as the USA, health insurance is commonly included in employer benefit packages and seen as an employment perk.
  3. 3. Why Do I Need Health Insurance? •As medical care advances, health care costs also increase. The purpose of health insurance is to help you afford your care. It will protect you financially, in the case of a serious medical issue. For some, health insurance may use their benefits for the occasional doctor’s visit or minor illness. Others may need the coverage and protection in the case of a catastrophic medical issue.
  4. 4. What Should I Look For? You many need some help narrowing your choices in the marketplace. Consider the following 4criteria when making your choice: • Health benefits: Which plan provides the must-have benefits you've identified? • Costs: Which plan falls within your budget when it comes to premium, deductible, copayments, and coinsurance? • Physician network: Do you have a doctor or doctors that you want to keep? • Prescriptions: Does the plan cover your medications?
  5. 5. Common Terms- Subscriber • Deductible: The amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying. • Dependent: Any individual, either spouse or child, that is covered by the primary insured member’s plan. • Out-of-pocket maximum: The most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year. • Premium: The amount you or your employer pays each month in exchange for insurance coverage.
  6. 6. Common Terms- Subscriber (cont.) • Participating Provider: Generally, this term is used in a sense synonymous with Network Provider. • Preauthorization/Precertification: These are terms that are often used interchangeably, but which may also refer to specific processes in a health insurance or healthcare context. • Primary Coverage: If a person is covered under more than one health insurance plan, primary coverage is the coverage provided by the health insurance plan that pays on claims first. See also, COB. • Referral: The process through which a patient under a managed care health insurance plan is authorized by his or her primary care physician to a see a specialist for the diagnosis or treatment of a specific condition.
  7. 7. Common Terms- HCP • Benefit: The amount payable by the insurance company to a plan member for medical costs. • Benefit year: The 12-month period for which health insurance benefits are calculated, not necessarily coinciding with the calendar year. Health insurance companies may update plan benefits and rates at the beginning of the benefit year. • Claim: A request by a plan member, or a plan member's health care provider, for the insurance company to pay for medical services. • Copayment: One of the ways you share in your medical costs. You pay a flat fee for certain medical expenses (e.g., $10 for every visit to the doctor), while your insurance company pays the rest.
  8. 8. Common Terms- HCP (cont.) • Coordination of benefits: A system used in group health plans to eliminate duplication of benefits when you are covered under more than one group plan. • Explanation of benefits: The health insurance company's written explanation of how a medical claim was paid. • In-network provider: A health care professional, hospital, or pharmacy that is part of a health plan’s network of preferred providers. You will generally pay less for services received from in-network providers because they have negotiated a discount for their services in exchange for the insurance company sending more patients their way.
  9. 9. Common Terms- Payer • Buy and Bill: This is a method of acquisition where the MD will purchase the medication wholesale and bill the insurance for both the drug and administration. • Coinsurance: A portion of the bill for a medical service, that is not covered by the patient's health insurance policy and therefore must be paid out of pocket by the patient. Coinsurance is calculated by a percentage. • Deductible: The amount of health care expenses a patient must pay before their health plan begins to pay for costs associated with a medical service. These amounts can change every year. • ICD-9: ICD Codes, International Classification of Diseases, are maintained in the United States by the CDC, and internationally by the World Health Organization.
  10. 10. Common Terms- Payer (cont.) • Lifetime Max: This is the maximum amount that your insurance company will pay during your lifetime. It is important to note that some plans also have an annual maximum. • Medical Policy: Guidelines that detail when certain medical services are considered medically necessary by a payer, and whether or not they are considered investigational. • Pre-Certification: Verification that a service, supply, therapy or medication is covered before rendered. It may also specify the conditions, medical setting, length of time or any other limits of your coverage. • Out of Pocket Maximum: The out-of-pocket maximum is the highest amount a health plan requires a patient to pay towards the cost of their health care.
  11. 11. Wrap-Up/Questions • When dealing with your HCP or Payer, be clear and concise with all questions relating to your care and applicable benefits. • Document all information received from payers along with the reference number of your call. This number can be referred to in the future should there be an issue with your coverage. • If it doesn’t sound right, it probably isn’t. Ask for clarification. • Google is always your friend. Many clinical policies can be found online, along with benefit details of plans. • Questions?

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