CH 11 Health, Disability & Long term Care Insurance
Wednesday, April 15, 2026 4:18 PM
Health Care Costs
- One of many ways people protect themselves against economic losses due to illness, accident and/or
disability
- Under President Obama in 2010, The Patient Protection & Affordable Care Act and the Education
Reconciliation Act, it was presented as reformed healthcare if the following ways:
○ Reduces health care costs for businesses & the govt
○ Protects families from bankruptcy/debt because of health care costs
○ Choice of doctor & health plans
○ Invest in your own wellness & health care prevention
○ Improve patient safety & quality of care
○ Affordable quality health insurance for all
○ Being able to keep coverage despite job change
○ Continue care to those w/ preexisting medical conditions
- High Medical Costs
○ Rapid Increase in medical expenses
§ In 1965 federally sponsored health care in the US has risen from 41.6 billion to 4 trillion in
2020
§ This increase doesn’t take into account the affect of COVID-19 because of the uncertain
nature of the pandemic
- High Administrative Costs
○ In the US admin costs are nearly 11% of the American dollar in usage, these are used for:
§ Enrolling beneficiaries
§ Health care payment premiums
§ Checking eligibility
§ Obtaining authorization for special/specific referrals
§ Reimbursement claims
Why Does Health Care Cost so much??
- The Use of high end expensive tech
- Multiple tests & tech that lead to similar results
- Various & frequent treatments, in some cases supposed unnecessary tests
- The rise in longevity & elderly people
- Regulations that cost more instead of less
- The increase in accidents & crimes that require medical emergency services
- Limited competition & restricted rules in the health care system
- High work volume demands while earnings for health care professionals stays the same
- Overuse of expensive medical care
○ I.E. going to urgent care for a cold instead of a deep cut/severe burn etc
- Aging Baby boomers who use more of these services, for more frequent doctors visits or more
expensive medications
○ Born between the 1950’s & more likely the late 60’s as of 2026, elderly in their early 60’s
- Other reasons health care is expensive
○ Fraud
○ Admin waste of resources
○ Insurance malpractice
○ Excessive surgical procedures
- According to the Govt Accountability office, fraud & abuse make up 10% of American earnings spent
on health care
○ Private health insurers & the govt pay a large part of the US health care bills, hospitals, doctors &
most people don’t use govt funded services
What is being done about the high costs of health care?
- Labor Unions, Health insurers, health care professionals & consumers have created activities to
attempt to contain the costs of health care:
○ Programs that reviews fee’s, charges & the use of health care services
○ Incentives for preventative care w/ services outside the hospitals, like pharmacies & clinics
○ Community involvement for better way to reach health care needs & have resources available
○ Prepaid services and/or small fee alternatives to needed services
○ Community health educational programs
○ Physician encouragement to pay cash for medical care & lab tests
What can you do reduce Personal Health Care costs?
- Try participating in a flexible spending account if offered by your employer
- Consider a high deductible healthcare plan that covers medical insurance & tax free opportunities for
possible future medical needs
- Ask your doctor/pharmacists for any generic name meds available, those are usually more affordable
- Use mail order services if provided or online pharmacies, usually best recommended for medications
you know that will be used for long term use
- Most states offer free and/or low cost coverage plans for children under 19 w/o health insurance
- Many states have state pharmacy assistance programs that offer financial assistance based on need,
age and/or medical conditions
- If your medical provider suggest non urgent procedures, ask for more info & time to think about it,
compare costs to websites like www.healthcarebluebook.com & New Choice Health
- Review billing statements from providers in case of errors
○ Appeal any unfair decisions made by your provider
- Practice preventative care & stay healthy
Best way to keep your self healthy are:
1. Eat a well balance diet & maintain weight
2. Avoid smoking & excessive drinking
3. Get enough rest, relaxation & exercise regularly
4. Be a cautious driver at all times
5. Maintain a healthy life in work & at home (work life balance)
6. Follow doctors recommendations & manage any health conditions
Health Insurance & Financial Planning
- What is Health Insurance?
○ A financial protection used in the event someone is injured or suffering illness
- Group Health Insurance
○ 90% are issued by health & life insurance companies and/or sponsored by your employer
○ The Tax Cut & Jobs Act of 2017
§ Required employers of 50 or more employees to provide health insurance for all employees
§ In June of 2018, US Dept of Labor expanded coverage to small businesses & employees via
Association Health Plan (AHP’s) that gave them coverage as a “large” business of
employment, this can be less expensive & meet the needs of employees
§ AHP’s don’t charge higher premiums
§ (HIPPA) Health Insurance Portability & Accountability Act of 1996
□ New federal law standards for health insurance, non discriminative & guaranteed
renewability
□ Under HIPPA you can change jobs and not loose your coverage
□ HIPPA is also used in medical settings to protect your personal/medical info
- Individual Health Insurance
○ This covers either one person and/or the whole family, be sure to shop around for options that
meet your exact needs so you don’t run into restrictions
- Supplementing your group Insurance
○ This is needed when your insurance fails to provide benefits for large portions of your medical
bills, hospital stays, doctors visits & surgical charges
○ Coordination of Benefits (COB)
§ A way to combine benefits under one or more insurances is used under allowed medical
expenses to receive 100% care
○ Medical Coverage & Divorce
§ Under federal law former spouses plans continue for 36 months if one party worker for an
employer exceeding 20 or more employees
§ (COBRA) Consolidated Omnibus Budget Reconciliation Act of 1986
□ Requires employers to offer their employees & dependents group health insurance for
a set period of time
□ Those who work in govt sectors are also covered however those who work for religious
institutions are not
Types of Health Insurance Coverage
- Hospital Expense Insurance
○ Pays part of the or the whole hospital bill for room, board and any other charges
- Surgical Expense
○ Pays for part of or the full amount of the surgical fees of an operation, the higher the costs the
higher the insurance premium
- Physicians Expense Insurance
○ Helps pay for the physicians care that doesn’t involve surgery
§ This can be combined w/ hospital stays & surgical visits known as basic health insurance
coverage
- Major Medical Expense Insurance
○ Protects against large expenses of a serious injury or long illness
- A deductible
○ Requires provisions for a policy holder to pay a basic amount to receive benefits
- Coinsurance
○ Provisions that require the policy holder to share expenses that go beyond the deductible
- Stop-Loss
○ Requires that the policy holder pay a certain amount after which the the insurance company
pays 100% of remaining expenses
- Comprehensive Major Medical Insurance
○ A type of insurance that has a very low deductible & is offered as a basic plan
- Hospital Indemnity Policies
○ Pays for benefits only when you are hospitalized, but are only paid in cash and can only be used
for medical purposes
- Dental Expense Insurance
○ Reimbursement/preventative dental care for oral exams, x-rays, cleanings, filings, extractions
etc
- Vision Care Insurance
○ Should include diagnosis, treating any eye diseases, periodic exams as required, glasses/contacts
& eye surgery if necessary
Other Insurance Policies
- Long Term Care Insurance (LTC)
○ Day in & day out care for those w/ an illness and/or a disability i.e. and elderly person depending
on a nurse for around the clock care
§ These cost between $100,000-$400,000/yr
§ Is recommend for those who need it over the age of 60 because it is costly
Major Provisions in a Health Insurance Policy
- Eligibility
○ Defines who is entitled to these benefits
- Assigned Benefits
○ A paper stating your insurance can make your payments should you be in the hospital
- Internal Limits
○ A limit that will only pay a set amount to your hospital room no matter the rate OR
○ It will cover your medical expenses to only a certain amount despite the charges
- Co payment
○ The amount a patient pays for medical services after the deductibles has been added
- Service Benefits
○ Insurance benefits to receive specified hospital or medical care
- Benefit Limits
○ Defines the maximum limit of benefits in either dollar amount and/or number of days one can
stay in the hospital for care
- Exclusions & Limitations
○ Are enforced under certain conditions/circumstances that a policy doesn’t provide, i.e. a check
up is covered but not a cosmetic procedure
- Coordination of Benefits
○ Benefits that come from you & your spouses policies when they are coordinated & allow you
100% payment coverage of medical charges
- Guaranteed Renewable
○ Insurance policies cant cancel services unless payment hasn’t been made, they also cant raise
premiums w/o a rate increase for all policyholders of said group
- Cancellation & Termination
○ An explanation from your insurance is given & the choice to change your policy from a group to
individual policy
Health Insurance Trade off’s
- Reimbursement vs Indemnity
○ Reimbursement - Provide benefits based on actual expenses incurred
○ Indemnity - Specified benefits regardless of expenses being greater/less than benefits
- Internal Limits vs Aggregate Limits
○ A policy w/ limits on max benefit expenses like reimbursements on hospital room & board,
others can be limited as high as 1million for major expenses w/ no limits at all
- Deductible & Coinsurance
○ A set amount that policy holders pay for medical expenses before the insurance company pays
○ They are also affected by what % of med costs the policy holder must pay plus the deductible
- Out of Pocket Limit
○ Some policies limit the amount of money you play for the deductible & Coinsurance, insurance
covers it 100% or any additional charges
○ You might lower financial risks, but your premiums will increase
- Benefits based on reasonable & customary charges
○ Some policies are considered average based on your location, w/ a set amount for policy holders
Which Coverage should you choose?
- You have 3 choices
1. Basic
2. Major Medical
3. Both basic & medical coverage
Private Source of Health Insurance & Health Care
- Private Insurance Companies
○ There are 800+ companies that offer the same services in health insurance
○ They are mainly sold as either group plans through an employer or as an individual plan
○ Group Insurances make up about 90% of medical expenses insurance & 80% disability income
insurance
- Insurance Policies either pay the healthcare provider directly OR reimburse the insured person for
their expenses
- Under HIPPA (Health Insurance Portability & Accountability Act)
○ Employers must keep records of coverage offered
○ Insurers must provide a Summary of Benefits & Coverage (SBC)
Hospital & Medical Service Plans
- Each state has either Blue Shield or Blue Cross & both plans have different offers
○ Blue Shield
§ Provides benefits for surgical & medical services done by doctors
○ Blue Cross
§ Provide hospital care benefits on a “service basis” where the hospital is reimbursed
Health Maintenance Organizations
- Managed Care
○ A prepaid health plan that provided services to their members
- (HMO) Health Maintenance Organization
○ A health insurance plan that contracts w/ certain physicians, surgeons, dentists & optometrists
for a prepaid monthly premium
○ Some HMO’s also cover Basic & Supplemental services
§ Basic Health Services
□ In/out patient, maternity, mental health, substance abuse & emergency care
§ Supplemental Services
□ Vision, hearing & pharmacy
Preferred Provider Organizations (PPO)
- A group of doctors & hospitals that all agree to provide care at certain rates approved by the insurer
○ PPO’s are slightly higher than HMO’s because of specified services & predetermined fee’s
○ Have the same fees & benefits
- Exclusive Provider Organization (EPO)
○ The extreme form of a PPO
§ Can receive treatment from an affiliated provider
§ You are not qualified for reimbursement
- Point of Sale plan (POS)
○ AKA Hybrid or open-end HMO
§ Use a network of various participating providers
Home Health Care Agencies
- In home health care plans
○ These plans have grown 20% in use for the following reasons
§ Elderly population is continuing to grow
§ Lower costs of care compared to institutional care in a facility
§ Insurers continue to offer & support this system
§ Medicare promotes home health as a better alternative
Employer Self-Funded Health Plans
- When your employer decides to run their own insurance plan & policies
New Health Care Accounts
Government Health Care Programs
- Medicare
○ Est 1965, a federal health insurance program for those 65+
○ For anyone who is suffering from kidney failure & certain disabilities
○ Medicare has 4 Parts
i. Medical Hospital Insurance (Part A)
• Used for those in inpatient care, in nursing facilities, home health & hospice care
ii. Medical Insurance (Part B)
• Pays for doctors services, other parts insurance will not cover but you MUST sign up to
receive these benefits
• The Balanced Budget Act of 1997 created The Medicare Choice program (today known
as the Medicare Advantage Plan) and allows you to combine Part A & B
iii. Medicare + Choice Program (Part C)
• Can be less expensive & offers extra benefits, can also assist w/ a discount on certain
medications
iv. Medicine/Drug Discounts (Part D)
• Medicare beneficiaries receive a discount on their medications
What is not covered by Medicare?
- Acupuncture
- Care in a nursing facility
- Skilled nursing care provided in certain facilities
- Intermediate & custodial nursing
○ Daily routine care
- Screening test, vaccines & diabetic supplies
- Private nursing
- Routine check ups, dental care, most immunizations, cosmetic surgery, glasses & hearing aids
Medi Gap
- AKA MedSup Insurance is not sold or serviced by the federal govt
Medicaid
- In 1965, Title XIX (Title 19) of Social Security provided a program known as Medicaid
○ Administered by the state following certain guidelines
§ (TANF) Temporary Assistance for Needy Families & Supplemental Security Income
- To qualify, state programs include various hospital services
○ In/out patient hospital services
○ Labs & X-rays
○ Nursing & home health services
○ Family planning
○ Screenings & Diagnosis
Health Insurance & The Patient Protection & Affordable Care Act of 2010
- The Affordable Care Act (ACA) set aside $635 billion over the period of 10yrs to help in the following
ways:
Here’s a clear, simplified summary of the bullet points:
• Tax Credit for small businesses
• Preventive care is now free (no co-pays or deductibles).
• Young adults can stay on their parents’ insurance until age 26.
• Lifetime limits on coverage are banned
• Annual limits are restricted to ensure people can keep getting care.
• Insurance plans must cover preventive services at no cost.
• You have the right to appeal insurance decisions (internally and externally).
• States provide consumer assistance programs to help with complaints and appeals.
• More funding was given to community health centers to serve more patients.
• Investments were made to increase the number of primary care doctors.
• Insurance companies must justify premium increases.
• Health insurance marketplaces (exchanges) were created to compare and buy plans.
• Medicaid was expanded for people with lower incomes.
• Larger employers must provide health insurance to employees.
The Affordable Care Act & The Individual Shared Responsibility Provision
- Under The Affordable Care Act
○ The Health Insurance Market Place
I looked closely at the pages you sent — they’re focused on disability insurance, not the Affordable Care Act specifically.
There’s no detailed ACA section in these images.
That said, I won’t leave you stuck — here’s a clean, copy-paste style summary of the Affordable Care Act (ACA) in the same
format you like 👇
Affordable Care Act (ACA) – Summary Notes
What it is:
The Affordable Care Act (ACA) is a U.S. law designed to make health insurance more accessible, affordable, and
comprehensive.
Main Goals
• Expand access to health insurance
• Reduce the number of uninsured people
• Lower healthcare costs
• Improve quality of care
Key Provisions
1. Individual Coverage (Individual Mandate)
• Originally required most people to have insurance or pay a penalty
• Federal penalty is now $0 (but some states still enforce it)
2. Health Insurance Marketplaces
• Online platforms to compare and buy insurance plans
• Provides standardized coverage options
3. Subsidies (Financial Help)
• Helps lower-income individuals afford insurance
• Based on income level
4. Medicaid Expansion
• Expanded eligibility to more low-income adults
• Not all states chose to expand Medicaid
5. Coverage for Preexisting Conditions
• Insurance companies cannot deny coverage or charge more due to health conditions
6. Essential Health Benefits
All ACA plans must cover:
• Doctor visits
• Emergency services
• Hospital care
• Maternity care
• Mental health services
• Prescription drugs
• Preventive care
7. Preventive Care
• Many preventive services are free (no copay)
○ Vaccines
○ Screenings
○ Checkups
8. Young Adult Coverage
• Can stay on a parent’s insurance until age 26
Protections for Consumers
• No lifetime limits on coverage
• Limits on annual out-of-pocket costs
• Clear explanation of benefits
Impact
• Increased number of insured Americans
• Improved access to healthcare
• Made insurance more standardized
Big Takeaways
• ACA = more access + more protection
• Helps people afford insurance
• Prevents discrimination based on health
• Focuses on prevention and long-term care
If you want, send the exact ACA page from your textbook, and I’ll match it exactly to your professor’s wording/style (that
helps a LOT for tests).
Wednesday, April 15, 2026 4:18 PM
Health Care Costs
- One of many ways people protect themselves against economic losses due to illness, accident and/or
disability
- Under President Obama in 2010, The Patient Protection & Affordable Care Act and the Education
Reconciliation Act, it was presented as reformed healthcare if the following ways:
○ Reduces health care costs for businesses & the govt
○ Protects families from bankruptcy/debt because of health care costs
○ Choice of doctor & health plans
○ Invest in your own wellness & health care prevention
○ Improve patient safety & quality of care
○ Affordable quality health insurance for all
○ Being able to keep coverage despite job change
○ Continue care to those w/ preexisting medical conditions
- High Medical Costs
○ Rapid Increase in medical expenses
§ In 1965 federally sponsored health care in the US has risen from 41.6 billion to 4 trillion in
2020
§ This increase doesn’t take into account the affect of COVID-19 because of the uncertain
nature of the pandemic
- High Administrative Costs
○ In the US admin costs are nearly 11% of the American dollar in usage, these are used for:
§ Enrolling beneficiaries
§ Health care payment premiums
§ Checking eligibility
§ Obtaining authorization for special/specific referrals
§ Reimbursement claims
Why Does Health Care Cost so much??
- The Use of high end expensive tech
- Multiple tests & tech that lead to similar results
- Various & frequent treatments, in some cases supposed unnecessary tests
- The rise in longevity & elderly people
- Regulations that cost more instead of less
- The increase in accidents & crimes that require medical emergency services
- Limited competition & restricted rules in the health care system
- High work volume demands while earnings for health care professionals stays the same
- Overuse of expensive medical care
○ I.E. going to urgent care for a cold instead of a deep cut/severe burn etc
- Aging Baby boomers who use more of these services, for more frequent doctors visits or more
expensive medications
○ Born between the 1950’s & more likely the late 60’s as of 2026, elderly in their early 60’s
- Other reasons health care is expensive
○ Fraud
○ Admin waste of resources
○ Insurance malpractice
○ Excessive surgical procedures
- According to the Govt Accountability office, fraud & abuse make up 10% of American earnings spent
on health care
○ Private health insurers & the govt pay a large part of the US health care bills, hospitals, doctors &
most people don’t use govt funded services
What is being done about the high costs of health care?
- Labor Unions, Health insurers, health care professionals & consumers have created activities to
attempt to contain the costs of health care:
○ Programs that reviews fee’s, charges & the use of health care services
○ Incentives for preventative care w/ services outside the hospitals, like pharmacies & clinics
○ Community involvement for better way to reach health care needs & have resources available
○ Prepaid services and/or small fee alternatives to needed services
○ Community health educational programs
○ Physician encouragement to pay cash for medical care & lab tests
What can you do reduce Personal Health Care costs?
- Try participating in a flexible spending account if offered by your employer
- Consider a high deductible healthcare plan that covers medical insurance & tax free opportunities for
possible future medical needs
- Ask your doctor/pharmacists for any generic name meds available, those are usually more affordable
- Use mail order services if provided or online pharmacies, usually best recommended for medications
you know that will be used for long term use
- Most states offer free and/or low cost coverage plans for children under 19 w/o health insurance
- Many states have state pharmacy assistance programs that offer financial assistance based on need,
age and/or medical conditions
- If your medical provider suggest non urgent procedures, ask for more info & time to think about it,
compare costs to websites like www.healthcarebluebook.com & New Choice Health
- Review billing statements from providers in case of errors
○ Appeal any unfair decisions made by your provider
- Practice preventative care & stay healthy
Best way to keep your self healthy are:
1. Eat a well balance diet & maintain weight
2. Avoid smoking & excessive drinking
3. Get enough rest, relaxation & exercise regularly
4. Be a cautious driver at all times
5. Maintain a healthy life in work & at home (work life balance)
6. Follow doctors recommendations & manage any health conditions
Health Insurance & Financial Planning
- What is Health Insurance?
○ A financial protection used in the event someone is injured or suffering illness
- Group Health Insurance
○ 90% are issued by health & life insurance companies and/or sponsored by your employer
○ The Tax Cut & Jobs Act of 2017
§ Required employers of 50 or more employees to provide health insurance for all employees
§ In June of 2018, US Dept of Labor expanded coverage to small businesses & employees via
Association Health Plan (AHP’s) that gave them coverage as a “large” business of
employment, this can be less expensive & meet the needs of employees
§ AHP’s don’t charge higher premiums
§ (HIPPA) Health Insurance Portability & Accountability Act of 1996
□ New federal law standards for health insurance, non discriminative & guaranteed
renewability
□ Under HIPPA you can change jobs and not loose your coverage
□ HIPPA is also used in medical settings to protect your personal/medical info
- Individual Health Insurance
○ This covers either one person and/or the whole family, be sure to shop around for options that
meet your exact needs so you don’t run into restrictions
- Supplementing your group Insurance
○ This is needed when your insurance fails to provide benefits for large portions of your medical
bills, hospital stays, doctors visits & surgical charges
○ Coordination of Benefits (COB)
§ A way to combine benefits under one or more insurances is used under allowed medical
expenses to receive 100% care
○ Medical Coverage & Divorce
§ Under federal law former spouses plans continue for 36 months if one party worker for an
employer exceeding 20 or more employees
§ (COBRA) Consolidated Omnibus Budget Reconciliation Act of 1986
□ Requires employers to offer their employees & dependents group health insurance for
a set period of time
□ Those who work in govt sectors are also covered however those who work for religious
institutions are not
Types of Health Insurance Coverage
- Hospital Expense Insurance
○ Pays part of the or the whole hospital bill for room, board and any other charges
- Surgical Expense
○ Pays for part of or the full amount of the surgical fees of an operation, the higher the costs the
higher the insurance premium
- Physicians Expense Insurance
○ Helps pay for the physicians care that doesn’t involve surgery
§ This can be combined w/ hospital stays & surgical visits known as basic health insurance
coverage
- Major Medical Expense Insurance
○ Protects against large expenses of a serious injury or long illness
- A deductible
○ Requires provisions for a policy holder to pay a basic amount to receive benefits
- Coinsurance
○ Provisions that require the policy holder to share expenses that go beyond the deductible
- Stop-Loss
○ Requires that the policy holder pay a certain amount after which the the insurance company
pays 100% of remaining expenses
- Comprehensive Major Medical Insurance
○ A type of insurance that has a very low deductible & is offered as a basic plan
- Hospital Indemnity Policies
○ Pays for benefits only when you are hospitalized, but are only paid in cash and can only be used
for medical purposes
- Dental Expense Insurance
○ Reimbursement/preventative dental care for oral exams, x-rays, cleanings, filings, extractions
etc
- Vision Care Insurance
○ Should include diagnosis, treating any eye diseases, periodic exams as required, glasses/contacts
& eye surgery if necessary
Other Insurance Policies
- Long Term Care Insurance (LTC)
○ Day in & day out care for those w/ an illness and/or a disability i.e. and elderly person depending
on a nurse for around the clock care
§ These cost between $100,000-$400,000/yr
§ Is recommend for those who need it over the age of 60 because it is costly
Major Provisions in a Health Insurance Policy
- Eligibility
○ Defines who is entitled to these benefits
- Assigned Benefits
○ A paper stating your insurance can make your payments should you be in the hospital
- Internal Limits
○ A limit that will only pay a set amount to your hospital room no matter the rate OR
○ It will cover your medical expenses to only a certain amount despite the charges
- Co payment
○ The amount a patient pays for medical services after the deductibles has been added
- Service Benefits
○ Insurance benefits to receive specified hospital or medical care
- Benefit Limits
○ Defines the maximum limit of benefits in either dollar amount and/or number of days one can
stay in the hospital for care
- Exclusions & Limitations
○ Are enforced under certain conditions/circumstances that a policy doesn’t provide, i.e. a check
up is covered but not a cosmetic procedure
- Coordination of Benefits
○ Benefits that come from you & your spouses policies when they are coordinated & allow you
100% payment coverage of medical charges
- Guaranteed Renewable
○ Insurance policies cant cancel services unless payment hasn’t been made, they also cant raise
premiums w/o a rate increase for all policyholders of said group
- Cancellation & Termination
○ An explanation from your insurance is given & the choice to change your policy from a group to
individual policy
Health Insurance Trade off’s
- Reimbursement vs Indemnity
○ Reimbursement - Provide benefits based on actual expenses incurred
○ Indemnity - Specified benefits regardless of expenses being greater/less than benefits
- Internal Limits vs Aggregate Limits
○ A policy w/ limits on max benefit expenses like reimbursements on hospital room & board,
others can be limited as high as 1million for major expenses w/ no limits at all
- Deductible & Coinsurance
○ A set amount that policy holders pay for medical expenses before the insurance company pays
○ They are also affected by what % of med costs the policy holder must pay plus the deductible
- Out of Pocket Limit
○ Some policies limit the amount of money you play for the deductible & Coinsurance, insurance
covers it 100% or any additional charges
○ You might lower financial risks, but your premiums will increase
- Benefits based on reasonable & customary charges
○ Some policies are considered average based on your location, w/ a set amount for policy holders
Which Coverage should you choose?
- You have 3 choices
1. Basic
2. Major Medical
3. Both basic & medical coverage
Private Source of Health Insurance & Health Care
- Private Insurance Companies
○ There are 800+ companies that offer the same services in health insurance
○ They are mainly sold as either group plans through an employer or as an individual plan
○ Group Insurances make up about 90% of medical expenses insurance & 80% disability income
insurance
- Insurance Policies either pay the healthcare provider directly OR reimburse the insured person for
their expenses
- Under HIPPA (Health Insurance Portability & Accountability Act)
○ Employers must keep records of coverage offered
○ Insurers must provide a Summary of Benefits & Coverage (SBC)
Hospital & Medical Service Plans
- Each state has either Blue Shield or Blue Cross & both plans have different offers
○ Blue Shield
§ Provides benefits for surgical & medical services done by doctors
○ Blue Cross
§ Provide hospital care benefits on a “service basis” where the hospital is reimbursed
Health Maintenance Organizations
- Managed Care
○ A prepaid health plan that provided services to their members
- (HMO) Health Maintenance Organization
○ A health insurance plan that contracts w/ certain physicians, surgeons, dentists & optometrists
for a prepaid monthly premium
○ Some HMO’s also cover Basic & Supplemental services
§ Basic Health Services
□ In/out patient, maternity, mental health, substance abuse & emergency care
§ Supplemental Services
□ Vision, hearing & pharmacy
Preferred Provider Organizations (PPO)
- A group of doctors & hospitals that all agree to provide care at certain rates approved by the insurer
○ PPO’s are slightly higher than HMO’s because of specified services & predetermined fee’s
○ Have the same fees & benefits
- Exclusive Provider Organization (EPO)
○ The extreme form of a PPO
§ Can receive treatment from an affiliated provider
§ You are not qualified for reimbursement
- Point of Sale plan (POS)
○ AKA Hybrid or open-end HMO
§ Use a network of various participating providers
Home Health Care Agencies
- In home health care plans
○ These plans have grown 20% in use for the following reasons
§ Elderly population is continuing to grow
§ Lower costs of care compared to institutional care in a facility
§ Insurers continue to offer & support this system
§ Medicare promotes home health as a better alternative
Employer Self-Funded Health Plans
- When your employer decides to run their own insurance plan & policies
New Health Care Accounts
Government Health Care Programs
- Medicare
○ Est 1965, a federal health insurance program for those 65+
○ For anyone who is suffering from kidney failure & certain disabilities
○ Medicare has 4 Parts
i. Medical Hospital Insurance (Part A)
• Used for those in inpatient care, in nursing facilities, home health & hospice care
ii. Medical Insurance (Part B)
• Pays for doctors services, other parts insurance will not cover but you MUST sign up to
receive these benefits
• The Balanced Budget Act of 1997 created The Medicare Choice program (today known
as the Medicare Advantage Plan) and allows you to combine Part A & B
iii. Medicare + Choice Program (Part C)
• Can be less expensive & offers extra benefits, can also assist w/ a discount on certain
medications
iv. Medicine/Drug Discounts (Part D)
• Medicare beneficiaries receive a discount on their medications
What is not covered by Medicare?
- Acupuncture
- Care in a nursing facility
- Skilled nursing care provided in certain facilities
- Intermediate & custodial nursing
○ Daily routine care
- Screening test, vaccines & diabetic supplies
- Private nursing
- Routine check ups, dental care, most immunizations, cosmetic surgery, glasses & hearing aids
Medi Gap
- AKA MedSup Insurance is not sold or serviced by the federal govt
Medicaid
- In 1965, Title XIX (Title 19) of Social Security provided a program known as Medicaid
○ Administered by the state following certain guidelines
§ (TANF) Temporary Assistance for Needy Families & Supplemental Security Income
- To qualify, state programs include various hospital services
○ In/out patient hospital services
○ Labs & X-rays
○ Nursing & home health services
○ Family planning
○ Screenings & Diagnosis
Health Insurance & The Patient Protection & Affordable Care Act of 2010
- The Affordable Care Act (ACA) set aside $635 billion over the period of 10yrs to help in the following
ways:
Here’s a clear, simplified summary of the bullet points:
• Tax Credit for small businesses
• Preventive care is now free (no co-pays or deductibles).
• Young adults can stay on their parents’ insurance until age 26.
• Lifetime limits on coverage are banned
• Annual limits are restricted to ensure people can keep getting care.
• Insurance plans must cover preventive services at no cost.
• You have the right to appeal insurance decisions (internally and externally).
• States provide consumer assistance programs to help with complaints and appeals.
• More funding was given to community health centers to serve more patients.
• Investments were made to increase the number of primary care doctors.
• Insurance companies must justify premium increases.
• Health insurance marketplaces (exchanges) were created to compare and buy plans.
• Medicaid was expanded for people with lower incomes.
• Larger employers must provide health insurance to employees.
The Affordable Care Act & The Individual Shared Responsibility Provision
- Under The Affordable Care Act
○ The Health Insurance Market Place
I looked closely at the pages you sent — they’re focused on disability insurance, not the Affordable Care Act specifically.
There’s no detailed ACA section in these images.
That said, I won’t leave you stuck — here’s a clean, copy-paste style summary of the Affordable Care Act (ACA) in the same
format you like 👇
Affordable Care Act (ACA) – Summary Notes
What it is:
The Affordable Care Act (ACA) is a U.S. law designed to make health insurance more accessible, affordable, and
comprehensive.
Main Goals
• Expand access to health insurance
• Reduce the number of uninsured people
• Lower healthcare costs
• Improve quality of care
Key Provisions
1. Individual Coverage (Individual Mandate)
• Originally required most people to have insurance or pay a penalty
• Federal penalty is now $0 (but some states still enforce it)
2. Health Insurance Marketplaces
• Online platforms to compare and buy insurance plans
• Provides standardized coverage options
3. Subsidies (Financial Help)
• Helps lower-income individuals afford insurance
• Based on income level
4. Medicaid Expansion
• Expanded eligibility to more low-income adults
• Not all states chose to expand Medicaid
5. Coverage for Preexisting Conditions
• Insurance companies cannot deny coverage or charge more due to health conditions
6. Essential Health Benefits
All ACA plans must cover:
• Doctor visits
• Emergency services
• Hospital care
• Maternity care
• Mental health services
• Prescription drugs
• Preventive care
7. Preventive Care
• Many preventive services are free (no copay)
○ Vaccines
○ Screenings
○ Checkups
8. Young Adult Coverage
• Can stay on a parent’s insurance until age 26
Protections for Consumers
• No lifetime limits on coverage
• Limits on annual out-of-pocket costs
• Clear explanation of benefits
Impact
• Increased number of insured Americans
• Improved access to healthcare
• Made insurance more standardized
Big Takeaways
• ACA = more access + more protection
• Helps people afford insurance
• Prevents discrimination based on health
• Focuses on prevention and long-term care
If you want, send the exact ACA page from your textbook, and I’ll match it exactly to your professor’s wording/style (that
helps a LOT for tests).
