medical insurance tale
TRANSCRIPT
Medical Insurance A Tale by Mrs. Tesora
Senior Medical Assisting Class
Class of 2017
Sharing a Language
Little Miss Muffet
Sat on a tuffet,
Eating her curds and whey;
Along came a spider,
Who sat down beside her,
And frightened Miss Muffet
away.
Sharing a Language
Little Miss Muffet
Sat on a tuffet, (foot stool)
Eating her curds and
whey; (cottage cheese)
Along came a spider,
Who sat down beside her,
And frightened Miss Muffet
away.
Sharing Words & Meaning •Beneficiary – The person that benefits from having insurance.
•Policy Holder – The person that signed up for and pays for the
medical insurance policy or “holds” the policy (plan).
•Guarantor – The person that will pay or guarantee to pay
any outstanding money owed after the medical insurance has paid
their part.
•Premium – The amount of money or cost paid to an insurance
company before (pre-) they are “covered” by medical insurance.
•Medical Insurance – An agreement with a policy holder who
pays a premium to ensure the insurance company will honor or pay
for certain medical costs as outlined in the written agreement or
plan.
Sharing Words & Meaning •Copayment – The amount of money that the
person receiving care or the guarantor pays at the
time care is provided.
•Explanation of Benefits EOB – A written document that
outlines the medical bill:
Fees/costs of medical care rendered or delivered by
hospitals, medical providers and testing facilities at the
point/place of care – poc.
The EOB also explains the fees paid by the insurance
company and the guarantor pays (copayments,
deductibles).
Sharing Words & Meaning •Preauthorization – Before (pre-) services can
be rendered some services outlined in the plan will
require the insurance company to authorize
(agree) to pay for out of medical need (necessity).
•Referral – When a provider recommends or
refers someone for services needed. This is a formal
request to the insurance company for
preauthorization.
•Deductible – An amount of money that the
patient has to pay for medical services before the
medical insurance plan begins to pay.
Purpose Why is the Medical Insurance important?
The purpose of Medical Insurance is to help a
person afford the cost of medical care.
What is the number one reason families
in America go Bankrupt?
Chronic, Acute or Catastrophic Illness.
Think about: Are there any hidden costs of
serious illness that insurance does not cover?
Purpose Why is the main Medical Insurance
important?
“When you are sick, the last thing you want to worry
about is if you can access the care you need.”
What is the number one reason families
in America go Bankrupt?
“Americans that have a sick person in their family
are very likely to experience poverty.”
Purpose Hidden / Not covered Costs:
•Lost income – Can you work?
•Copayment/Deductibles/Premiums – How
much does that cost?
•Over the counter (OTC) medicine, Durable
Medical Equipment (DMEs) not covered.
Think about it: What is the advantages of Home
care vs. Tertiary Care (Long Term Nursing Home) for
the elderly and disabled?
Types of Coverage / Plans Traditional Insurance (e.g. Blue Cross / Blue Shield) Fee for Service
Managed Care (HMO, POS, PPO)
•Pays fees per contracted agreements
•Health Maintenance Organization (HMO)
•Exclusive to a network of providers
•Point of Service (POS)
•Freedom to go outside network
•Preferred Provider Organization (PPO)
•Insurance company has an agreement
for a discounted rate in network
Understanding the Types of Coverage Medicaid – (MassHealth Standard) The
disabled and poor people are eligible.
Medicare – Seniors (over 65) and permanently
disabled people are eligible.
Explanation of Benefits (EOB) Explanation of Benefits
Patient: Jack
Diagnosis: Broken Crown
Health Care Service Fee Insurance Payment
ER Visit $400 $300
CT Scan $8,000 $7,500
Suturing $170 $170
Total $8,570 $7970
Balance Due $600
Co-pay -$100
Deductible not met $500 What does
Jack owe?
Medicaid Humpty Dumpty sat on a wall.
Humpty Dumpty had a great fall.
All the kings horses and all the kings men couldn’t put Humpty together again.
Humpty now lives with a chronic debilitating condition – Broken Egg Syndrome – and is now disabled.
What medical insurance would cover him?
State Medicaid/
MassHealth Standard
Or
Medicare if Brown Egg
Syndrome permanently
prevents Humpty from
working.
Medicaid / MassHealth Standard
There was an old woman who lived in a shoe.
She had so many children, she didn't know what to do.
She gave them some broth without any bread;
And whipped them all soundly and put them to bed.
The Children's Health
Insurance Program (CHIP)
provides low-cost health
coverage to children in families
that earn too much money to
qualify for Medicaid.
Definition of Poverty 2016 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND
THE DISTRICT OF COLUMBIA
PERSONS IN
FAMILY/HOUSEHOLD POVERTY GUIDELINE
For families/households with more than 8 persons, add $4,160 for each
additional person.
1 $11,880
2 16,020
3 20,160
4 24,300
5 28,440
6 32,580
7 36,730
8 40,890
Understanding the Types of Coverage Traditional Insurance –
Remember Jack & Jill have Blue Cross / Blue Shield
Medicaid –
Think Humpty Dumpty / Disabled People with
limited income. The Woman that Lived in a Shoe
/ Poor People that have no money or that are
living in poverty (400% below the poverty line
for MassHealth)
Medicare –
Remember Rip Van Winkle – Old Man
Medicare
Rip Van Winkle went
for a hike to get away
from his nagging wife
Unable to handle the
pressures of having a
job, he drank some
moonshine and fell
asleep on a log.
To his surprise when
he awoke…
Medicare
He had aged
many years!
As an old many he had
many fears.
How will Rip pay for
his medical bills?
Medicare
He had aged
many years!
As an old man he had
many fears.
How will Rip pay for
his medical bills?
MEDICARE?
Medicare
Medicare A – Hospital ($$$$)
Medicare B – Outpatient ($$$)
Medicare C - Consumer /
Commercial
(Examples: Medicare Advantage,
Senior Care Options)
Medicare D – Remember Donut
Hole and Prescriptions
Medicare
Is he really eligible?
Did he worked long enough and
paid into Medicare through his
employment taxes?
If he did not work long enough or had a
disabling condition that prevented him
from working, what insurance would
cover him other than Medicare?
Advanced Learning Credit
1. Tell me about armed forces and their families Medical Care?
2. Describe a Provider Network (e.g. Partners)
3. Process map the “Referral Process”.
4. Demonstrate and understanding in your preferred method (outline, charts/graphs, poster, oral presentation) of Worker’s Compensation.
5. Identify a type of organization or a business that is “self-insured”.
Explore a Career in Healthcare Billing American Academy of Professional Coders
(AAPC) at http://aapc.com
American Health Information Management (AHIMA) at http://www.ahima.org
American Medical Billing Association (AMBA) at http://www.ambanet.net
National Association of Claims Assistance Professional (NACAP) at https://www.medical-codingbilling.com
National Electronic Billers Alliance (NEBA) at http://www.nebazone.com/part1.html