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Healthcare Problems in US
Rising Healthcare Expenditures Inadequate Access to Medical Care Uneven Quality of Medical Care Inefficiency and Fraud
Self-Insured Plans
Retention Plans o Stop-Loss Insurance o TPAs
o
Health Insurance Costs may be reduced or increase less rapidly Cash flows of the premium Savings can be invested
Preadmission testing before admission to the Hospital Diagnostic X-Ray and Laboratory Services
Deductibles
Calendar year Deductible Family Deductible Deductible Carryover Provision Common accident Provision Corridor Deductible
Deductible Carryover
o Covered medical expenses of the last 3 months of the calendar can be carried over to the next year to satisfy next years deductible
Jan?
How much United Indias Health Insurance Pays to Dinesh and his Wife In Feb? How much United Indias Health Insurance Pays to Dinesh Father In Feb?
Case d: Dinesh incurs 200 , wife 245, and Father 300 for the expenses in one accident
How much United Indias Health Insurance Pays to Dinesh towards this accident Expenses?
Preexisting Conditions
o To Reduce Adverse Selection
Portability-HIPAA
Limiting Coverage for pre-existing condition ( Exception: Pregnancy, newly born Children, Adopted Children)
Dental Insurance
Dental Insurance
Skilled Nursing Care, Intermediate Nursing Care, and Custodial Nursing Care
Daily Benefit
Maximum Lifetime Benefit
Elimination Period Eligibility Gate Keeper Provisions based on ADLs Protection against inflation Guaranteed renewability Cost increases with age
PPOs
EPOs POS
Advantages o o o o
Lowers healthcare Costs Members pay little or no out-of-pocket costs Loss Prevention Services No need to file claims
Disadvantages
Total Disability
o
o o o
Residual disability
Elimination Period Benefit Period Renewability of the policy
Guaranteed
Renewable renewable
Non-Cancelable Conditionally
Waiver of premium
. Costly Rider
Guaranteed Insurability Rider can purchase additional amount of insurance
Short term elimination period of 1 to 7 days for sickness and accidents are
covered from the fist day of disability Elimination period reduces the costs down and reduces absenteeism and Laziness
o o
o
o o o
o Substantial gainful work and disability should last for at least 12 months or death. Claim will not be allowed if the person can engage in any other substantial work
Benefits
o Monthly benefits
Medicare
Covers medical expenses of most individuals of age sixty-five or older To disabled individuals under age 65 for disability benefits for 24 months Aged under 65 for long term kidney dialysis or kidney transplant
Part A Hospital Insurance Part B- Supplementary Medical Insurance Part C - Medicare + Choice Program
Medicare- Part A
Skilled Nursing Facility Care Home Health care services Hospice Care ( Terminally ill) Blood Transfusions (except first three pints)
Medicare- Part A
Medicare- Part B
Voluntary program that pays for physicians fees, out patient hospital
services etc Part A automatically includes Part B, unless declined
Medicare + Choice
Balanced Budget Act of 1997 Original Medicare Original Medicare Plan with Supplemental Policy
Medicaid
Federal-State welfare program that covers the medical expenses of low-income persons, including those who are aged, blind, or disabled; members of families with dependant children; and pregnant women as well as certain children
Workers Compensation
Social Insurance providing health and Disability Insurance to employed workers Covered employers pay benefits to workers who have a job related injury or disease
Workers are not required to sue Employers Benefits paid based on a schedule of benefits established by law
Eligibility
Benefits
Thanks !!