101 everything you wanted to know about health insurance (and aren’t afraid to ask) an...
TRANSCRIPT
101Everything you wanted to know about health
insurance (and aren’t afraid to ask)
An informational service of the Texas Federation of Teachers
Health InsuranceHealth Insurance
Consumer Concerns:Consumer Concerns:
Access to quality health care.Affordable cost.
IndemnityHMO
PPO
deductible
Co-insurance
Co-pay
Pre-existing condition
Plan maximum
In-network and out-of-network
Primary care physician
Hospital pre-certification
Medical plans--whether group plans or individual plans--are designed to insure against financial ruin...
as a result of someone getting sick or injured
•Plan Type•Age•Gender•Health Status•Number Insured
Cost DriversCost Drivers
Types of Medical PlansTypes of Medical Plans
Traditional or Indemnity Preferred Provider Point of Service Health Maintenance Organization
How Managed Indemnity WorksHow Managed Indemnity Works
Member seekshealth care
Anyprovider
Member precertifiesand files claims
Deductible Coinsurance Benefits
How PPOs WorkHow PPOs Work
Member seeks health care
In-networkproviderLower deductibleOffice visit co-paysPreferred coinsurancePreferred benefits
Out-of-networkproviderDeductibleCoinsuranceNonpreferred benefits
Provider precertifiesand files claims
Member precertifiesand files claims
How POS Plans WorkHow POS Plans Work
Member seekshealth care
Primary carephysician (PCP)No deductibleFixed co-paysPreferred benefits
Any provider Deductible Coinsuranced Nonpreferred benefits
Other networkproviders (e.g.specialists)
Referral
Provider precertifiesand files claims
Member precertifiesand files claims
How HMOs WorkHow HMOs Work
Member seekshealth care
Primary carephysician (PCP)No deductibleFixed co-paysPreferred benefits
Any provider No coverage
Other networkproviders (e.g.specialists)
Referral
Provider precertifiesand files claims
Ancillary InsuranceAncillary Insurance
Maternity First Dollar accident Dental Prescription drugs Life insurance Long-term care Disability
AFT/TFT Optional Benefit PlansAFT/TFT Optional Benefit Plans
Disability Life insurance Long-term care Short-term major medical
Texas State Health Insurance ProgramTexas State Health Insurance Program
Point of Service Plan Texas pays all of employee-only premium. Texas pays 1/2 of additional family premium.
In sum, Texas pays 67.3% of total family plan cost.
Apples to Apples: ERS to ISDApples to Apples: ERS to ISDERS ISD
Employee Only $
Family $
Employee Only %
Family %
The TFT Initiative for state-paid The TFT Initiative for state-paid health insurancehealth insurance
Town hall meetings
Petitions
Local School Board resolutions
Letters and faxes to legislators
Testimony to legislative committee
TFT Legislative CommitmentTFT Legislative Commitment
A health insurance plan at least as good as that of state employeesFully paid “employee only” premiumHalf of additional premium for family coverage