9 Health and Disability Income Insurance • Eases the financial burden people may experience as a result of illness or injury (pay a premium to transfer risk of loss) – Medical expense insurance- pays actual medical costs – Disability income insurance- provides replacement income • Group and individual health insurance coverage available • COBRA – Requires many employers to offer employees and dependents the option to continue their group coverage for a set period of time following a layoff • The Health Insurance Portability and Accountability Act – Established federal portability standards – If you change jobs, you need not lose your health insurance 9-1
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9 Health and Disability Income Insurance
• Eases the financial burden people may experience as a result of
illness or injury (pay a premium to transfer risk of loss)
– Medical expense insurance- pays actual medical costs
– Disability income insurance- provides replacement income
• Group and individual health insurance coverage available
• COBRA – Requires many employers to offer employees and dependents the option
to continue their group coverage for a set period of time following a layoff
• The Health Insurance Portability and Accountability Act
– Established federal portability standards
– If you change jobs, you need not lose your health insurance9-1
Sources of Health Care Plans
• Health Care Plan- generic name for any program that pays or provides reimbursement for health care expenses
• Group Health Care Plan – health coverage sold collectively to an entire group of persons rather than to individuals
• Open Enrollment Period – during this time, you can begin or make changes in coverage or switch among alternative plans– Requirements are generally waived for family
changes (e.g., birth of a child, adoption, marriage)
• Group Plans:
– Covers most individuals
– Usually employer sponsored (also unions, trade groups)
– Employer pays part or most of cost
• Coordination of Benefits: combine benefits from >1 plan– Benefits received from all sources limited to 100% of
allowable medical expenses
– Married couples/partners need to consider
Objective 1Recognize the Importance of Health
Insurance in Financial Planning
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Objective 2Analyze the Costs and Benefits of Various Types of Health Insurance as well as Major Provisions in Health Insurance Policies
Types of Health Insurance Coverage
Basic Major medical Both
• Basic Health Insurance– Hospital Expense Insurance
• Hospital room, board, and other charges (usually with a cap)
– Surgical Expense Insurance• Surgeon's fee for an operation (often specify amount per service)
– Physician Expense (Medical Expense) Insurance• Pays for physician’s care that does not include surgery, such as
• Major Medical Expense Insurance– Covers expenses for serious injury or long-term illness
– Goes beyond what basic health insurance pays
– May include a deductible (initial amount paid before insurance co. pays), coinsurance (e.g., 20% to 25% of expenses after deductible), and a stop-loss provision
– Policy limits of $1 million are common
– Stop-loss: policyholder pays coinsurance up to a certain amount, after which insurance company pays 100% (typically $3,000 and $5,000)
– Comprehensive Health Insurance- combines basic health insurance and major medical into a single policy
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Types of Health Insurance Coverage
• Hospital Indemnity
– Pays you a fixed amount for each day you are hospitalized
– Does not cover medical costs
– Supplement to the other plans
• Dental Expense Insurance
– Covers exams, cleaning, x-rays, fillings, root canals, and oral surgery
• Vision Care– Exams, contact lenses, and glasses
• Dread Disease Policies– Pays out for very specific conditions (e.g., cancer)– Illegal in many states
• Long-Term Care Insurance– Virtually unknown 25 years ago– Covers daily help if seriously ill or disabled– Nursing home or in-home care
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Major Provisions in a Health Insurance Policy
• Eligibility– Varies with age, marital status, and dependency
• Assigned Benefits– Insurance pays your doctor or hospital directly
• Internal Limits– Fixed amount per day for a hospital room
• Copayment– Cost sharing in the form of a flat dollar amount
you pay, such as $15 per office visit or $10 per prescription
– NOT the same as co-insurance, which is a percentage of expenses 9-7
Major Provisions in a Health Insurance Policy
• Service Benefits – Entitlement to specific services
• Benefit Limits
– Maximum dollar amount or maximum number of days in the hospital
• Exclusions and Limitations– Pre-existing conditions
– Cosmetic surgery
• Guaranteed Renewable (can’t cancel policy unless fail to pay premiums; insurer can’t raise premiums for one person unless raised for an entire group)
• Cancellation and Termination – Explains the circumstances under which policy can be
canceled and/ or converted 9-8
Objective 3Assess the Trade-offs of
Different Health Insurance Plans
Trade-Offs in Choosing a Policy
• Reimbursement versus indemnity– Reimbursement pays actual costs
– Indemnity pays specific amounts (regardless of expenses)
• Internal (fixed amount per expense) vs. aggregate limits
• Deductibles and coinsurance• Out-of-pocket limits (after reach limit, get 100% coverage)
• Benefits based on reasonable and customary charges (policy won’t pay more than that amount)
9-9
Health Insurance Must-Haves
9-10
Objective 4 Evaluate the Differences Among
Health Care Plans Offered by Private Companies and by the
Government
Private Health Care Plans• Private Insurance Companies
– Individual policy– Group policy sold to an employer
• Hospital and Medical Service Plans– Blue Cross = hospital care – Blue Shield = surgical and medical services
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Private Health Care Plans
• Health Maintenance Organization (HMO)
– Managed care
• Prepaid health plan
• Primary care physician
– Contracts with selected care providers
– Fixed pre-paid monthly premium
– Focus is on prevention and wellness
– Usually pay small copayment to see doctor9-12
Private Health Care Plans• Preferred Provider Organization (PPO)
– Several providers to choose from
– Costs more than an HMO
– More choices, fewer restrictions than an HMO
– If you go to a non-PPO provider, you pay more
– Example: NJ Direct for state of NJ employees
• Point-of-Service (POS)– Combines features of HMOs and PPOs
• Home Health Care Agencies– Medical care in a home setting for a fraction of the cost of hospitals
• Employer Self-Funded Health Plans– Company runs self-insured insurance program
– Collects premiums from employees
– Pays medical benefits as needed 9-13
New Health Care Accounts
• Health Spending Accounts (HSA)– Money contributed to pre-tax dollar account
– Must have a high-deductible policy
• Health Reimbursement Accounts (HRA)– Also tied to high-deductible policies
– Funds managed by employer– Unused funds forfeited at year end 9-14
Government Health Care Programs
• Medicare
– Federally funded health insurance program
– Covers those age 65+ and certain disabled persons
– Does not cover everything
– Patient liable for the difference in costs
– Program in financial trouble; needs changes
– 4 parts: A, B, C, D
• Medicaid- health care program for the poor that is jointly administered and funded by the federal and state governments
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MEDICARE• Part A:
– Hospital insurance helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care, and hospice care (paid for by workers’ payroll deductions)
• Part B: – Medical insurance helps pay for doctors’ services and many other
medical services and supplies not covered by hospital insurance
– Beneficiaries pay a monthly premium (varies according to income)
• Part C:– Medicare Advantage plans available in many areas– Those with Parts A and B can choose to receive all of their health care
services through one of these provider organizations under Part C
• Part D: – Prescription drug coverage helps pay for medications doctors prescribe