Expert answer:The 2010 Health Reform Law, 3-4 health and medical
Answer & Explanation:1. Introduction (25%) Provide a
brief synopsis of the meaning (not a description) of each Chapter and articles
you read, in your own words that will apply to the case study presented.
2. Your Critique (50%)
Case Study:
Mr. Job Bob owns a small business that sells
medical equipment. He has nine employees and has always made it a priority to
offer competitive benefits, including health insurance. Unfortunately, last
year one of his employees was diagnosed with Cancer, which he continues to
fight. Due to the sharp increase in use of health services by his employee
group, the insurance company doubled his group premiums for upcoming year. When
Mr. Jib Bob contacted others carriers, several of them would not consider
insuring his group, and most of the others gave him quotes as expensive as his
current carrier. After reviewing his company’s finances, Mr. Bob is left with
several unattractive options:
Stop Offering HealthOffer Comprehensive health insurance but pass
on the cost increase to his employees, which would make it unaffordable or most
of them.Offer the bare-bones catastrophic plan only,Significantly lower wages and others benefits
to defray the rising health insurance costs.
In
addition to wanting to offer competitive benefits, Mr. Bob is concerned that
adopting any of these options will cause his employees to leave and make it
hard to attract others, threatening the sustainability of his company.
CASE STUDY CHALLENGE:
Mention, describe and discuss the best option for Mr. Bob’s Company
and Employees.Apply and comment if the 2010 Health Reform Law, The patient
Protection and Affordable Care Act will contribute to the solution or no of Mr.
Job Bob and employee’s insurance issue. Why?
3. Conclusion (15%)
Briefly summarize your thoughts &
conclusion to your critique of the case study and provide a possible outcome
for Health Insurance. How did these
articles and Chapters influence your opinions about Health Economics in a
Health Policy Context?
Evaluation
will be based on how clearly you respond to the above, in particular:
a) The
clarity with which you critique the case study;
b) The
depth, scope, and organization of your paper; and,
c) Your
conclusions, including a description of the impact of these Case study on any
Health Care Setting.
chapter_5.pdfhealthguide.pdf
chapter_5.pdf
healthguide.pdf
Unformatted Attachment Preview
Health Insurance and
Health Maintenance Organizations
A Guide for Consumers
Contents
4
Consumer
Traditional Versus Managed Care
Coverage
5
Major Medical Insurance
6
Types of Major Medical
Coverage
7
Self-Employed Plans
8
The Affordable Care Act (ACA)
HELPLINE
1-877-693-5236
or visit our Website at:
www.MyFloridaCFO.com
13 Other Health – Related Policies
15 Health Savings Accounts
15 Continuation of Coverage
17 Things to Consider When
Comparing Health Care
Options
18 Questions and Answers About
Premiums
20 Consumer Tips
21 Filing Claims
22 How to Select an
Insurance Company
22 How to Select an Insurance Agent
23 Your Rights and Responsibilities
24 Insurance Discrimination
Against Victims of Abuse
24 Seniors: Need Help With Your
Insurance Questions?
25 Medical Privacy and the Medical
Information Bureau
NOTE:
Most health insurance rates in Florida
are regulated by the Office of Insurance
Regulation (OIR). The OIR’s rate approval
authority for non-grandfathered individual and
small group policies was removed for the 2014
and 2015 policy years during the 2013
Legislative session. Other financial services are
regulated by the Office of Financial Regulation
(OFR). Although both are administratively
housed within the Department of Financial
Services (DFS), they are separate entities that
report to the Florida Cabinet. Because DFS
handles consumer-related matters, consumers
should remember that DFS is their point of
contact for all problems and questions.
The Florida Department of Financial Services
distributes this guide for educational purposes
only; it does not constitute an endorsement for
any service, company or person offering any
product or service.
Copyright ©2013 Florida
Department of Financial Services
26 Insurance Fraud Costs Us All!
27 Glossary
Printed on partially recycled paper
2
Health Insurance
Nobody plans on getting sick or injured. But life is full of unexpected events that
force us to seek medical care. These include everything from a common cold to a
more prolonged illness or injury. When these situations arise, your best financial
defense is to have adequate health insurance.
Health insurance can help protect your assets and pay medical expenses, but
selecting the policy to best meet your needs can be challenging. This guide explains
the various types of policies that are available, offers tips on choosing a policy and
provides definitions for the numerous health insurance terms you may encounter.
This brochure also includes information regarding the federal Affordable Care Act
(ACA) – also known as federal health care reform. If you have any questions after
reading this guide, please call the Florida Department of Financial Services (DFS)
Consumer Helpline toll-free at 1-877-MY-FL-CFO (1-877-693-5236) or 850-413-3089
if calling from out of state.
3
TRADITIONAL VERSUS MANAGED CARE COVERAGE
Your first health insurance choice may be to
decide between traditional health insurance
and a managed care option. Most individual
and group policies sold today are managed
care contracts. The difference between the
two types of plans affects how you access
care. With traditional health insurance, you –
the policyholder – select a health care
provider, such as a doctor or hospital. You
may have to pay for services when rendered
and then submit the bill to the insurance
company for reimbursement of the portion it
agreed to pay under the policy terms.
Frequently, the provider will submit the bill
directly to the insurer and await payment.
The managed care system combines the
delivery and financing of health care services.
This limits your choice of doctors and
hospitals. In return for this limited choice,
however, you usually pay less for medical
care (i.e., doctor visits, prescriptions, surgery
and other covered benefits) than you would
with traditional health insurance. The
managed care network controls health care
services.
Types of Managed Care
Health Maintenance Organizations
(HMOs)
HMO plans offer a wide range of health care
services through a network of providers. An
HMO gives subscribers access to certain
doctors, hospitals and other providers within
its network. The network is made up of
providers who agreed to supply services to
members for pre-negotiated rates as well as
meet certain quality standards. Unlike other
insurance plan types, care is covered only if a
subscriber sees a provider within the HMO’s
network, except in case of an emergency.
There are a few opportunities to utilize a nonnetwork provider – primarily when services are
not available in the network. As a member of an
HMO, members are usually required to choose a
primary care physician (PCP). PCPs direct most
of a subscriber’s health care needs. Some HMOs
require a referral before a subscriber can visit a
specialist. A Florida medical provider, whether
contracted or not, is prohibited from balance
billing an HMO subscriber if the service provided
is covered by the health plan.
Preferred Provider Organizations(PPOs)
PPO plan members generally see specialists
without a prior referral or authorization from the
insurer. The member should only be responsible
for the policy co-payment, deductible, or coinsurance amounts if covered services are
obtained from in-network providers. However, if a
policyholder chooses to obtain services from an
out of network provider, the member can be billed
for the difference between an out of network
provider‘s charges and the insurer’s approved
amount.
Exclusive Provider Organizations (EPOs)
In an EPO arrangement, an insurance company
contracts with hospitals, physicians, and other
medical facilities. Insured members must use the
contracted hospitals or providers to receive
covered benefits from this type of plan. An EPO
combines features of an HMO and a PPO plan.
Point-of-Service Plans (POS)
Point of Service plans are an HMO product with a
rider that allows the subscriber to obtain services
from out of network providers. These plans may
be called by a variety of names with various
features. They combine some aspects of
traditional medical expense insurance plans with
other aspects of HMOs and PPOs. In a POS plan,
insured members may choose, at the point of
service, whether to receive care from a physician
within the plan’s network or go out of network.
4
Point-of-Service Plans (continued)
The POS plan provides less coverage for
health care expenses obtained outside the
network than for expenses incurred within
the network through higher deductibles, coinsurance, co-payment or maximum out of
pocket expenses. Subscribers can also be
responsible for the difference between the
out of network provider’s charges and the
HMO’s approved amount.
The federal Affordable Care Act (ACA)
requires all non-grandfathered health plans to
provide a minimum set of ten benefits called
Essential Health Benefits. These benefits are
all provided through a form of managed care
plan (PPO, EPO, HMO, or POS) beginning
January 1, 2014. Consumers should pay
close attention to the provider network under
the available plan options. More details about
coverage under the ACA is discussed later in
this brochure.
MAJOR MEDICAL INSURANCE
These policies provide protection against the
high costs of hospitalization, injuries and
serious or ongoing illnesses. Other possible
coverages include the cost of blood
transfusions, drugs and out-of-hospital costs,
such as doctor visits as well as prescription
drugs. Most group health policies fall under
the category of major medical policies.
Major medical policies cost extra and provide
more benefits than basic policies. A major
medical policy normally pays 70 – 80 percent
of covered expenses, after you pay the
deductible. Most major medical plans
stipulate that the contracted provider, if there
is one, cannot charge for the actual cost in
excess of the contracted amount. For noncontracted providers, the insurance
companies use fee schedules to determine
the average cost of a procedure; however,
this cost may differ from the actual charge
you receive and you will be responsible for
the difference.
Maximum out-of-pocket limits restrict the
amount of health care expenses you pay.
This amount can include your deductible,
copayments, and coinsurance amounts. It
does not include your premium. Once the
maximum out of pocket is reached, the plan
will pay 100 percent of remaining covered
expenses. Read your policy to determine the
out of pocket maximum and the list of
expenses that count toward this amount.
5
TYPES OF MAJOR MEDICAL COVERAGE
Group Plans
Fulfilling your insurance needs may prove
relatively simple if your employer offers a
group plan or a choice of plans. Group plans
cover several people or groups under one
policy. You will receive a certificate of
coverage that acts as your policy when you
obtain insurance through a group plan. Most
group policies are suitable for the average
person and may include provisions to cover
family members.
Businesses with two to 50 employees will be
referred to as small group health coverage.
The ACA will broaden the small group health
market to include those employers with
between 2 and 100 employees starting in
2016. Self-employed individuals or businesses
with only family members working will obtain
coverage through the individual health
insurance market.
For more information on small group plans
contact our Consumer Helpline toll-free at
1-877-MY-FL-CFO (1-877-693-5236), or you
may download our Small Business Owners’
Insurance guide from the DFS Website at
www.MyFloridaCFO.com.
Individual Plans
Individual plans cover one person or
all members of a family under one
policy. Usually, people buy individual
plans because they lack access to
employer-based group policies.
Others use individual health policies
during periods of unemployment
when they lack coverage under group
policies. If you buy an individual policy,
you have a free-look period of 10 days
from the date you receive the policy to
decide whether to keep or cancel it.
For a full refund, you must return the
policy to the company within the allowed
time. If you reject the policy, you should
return it by registered or certified mail.
This may help you avoid a potential
dispute regarding the return of the policy
within the required time frame.
Consumer Alert
By statute, applications for medical coverage
not governed by Florida law must contain a
disclosure statement in contrasting color near
the signature block declaring what state
governs the coverage and the ramifications
of not purchasing coverage governed by
Florida’s consumer protections. Furthermore,
certificates issued under a policy approved
by another state must contain the following
statement, generally found on the front page:
“The benefits of the policy providing your
coverage are governed primarily by the laws
of a state other than Florida.” These
disclosures should prompt you to ask further
questions about the laws governing this
coverage and the resulting suitability of this
coverage for your needs.
6
IN ADDITION TO MAJOR MEDICAL PLANS,
THERE ARE SELF-EMPLOYED PLANS
Traditional health insurance and managedcare plans form major parts of the
American health care system. However,
employers may select an alternative to
cover health expenses and meet
employees’ needs. This is known as a
single-employer plan.
If you are covered under a single employer,
non-government entity and have been
unable to resolve a service or claim issue by
contacting the employer, then you may want
to contact the USDOL for assistance by
calling 1-866-444-3272 or by visiting their
website at www.dol.gov.
These plans fall under the guidelines of the
federal Employee Retirement Income
Security Act (ERISA). Employers establish
these plans to provide health care and/or
other employment benefits to employees,
their families and dependents. An insurance
carrier may fully insure a group health
ERISA plan or the employer may opt for
self-insurance.
Facts to Consider
Group and individual health insurance
plans usually offer coverage for family
members. Family policies generally pay
benefits for your spouse and dependent
children up to the age specified in the
policy. However, your insurance company
cannot terminate coverage for dependent
children due to age who lack other means
of support due to mental or physical
handicaps.
Employers participating in a self-insured
plan assume the financial risks involved,
rather than transferring this risk to an
insurance carrier. The employer pays for
claims filed by employees covered by the
plan. Many of these plans hire an insurance
company to handle paperwork with the
company acting as a third-party
administrator, but it does not assume any
legal obligation to pay claims. DFS nor the
Office of Insurance Regulation (OIR)
regulates self-insured, single-employer
plans since they fall under the jurisdiction of
the United States Department of Labor
(USDOL). In addition, the Florida Life and
Health Guaranty Fund, which pays losses to
policyholders when certain insurance
companies become insolvent, does not
cover such plans.
Policy benefit requirements can vary
depending on whether or not your group or
individual health plan is considered a
grandfathered or non-grandfathered health
plan under the federal Affordable Care Act
(ACA). You can verify the type of plan you
have with your current insurer.
7
THE AFFORDABLE CARE ACT (ACA)
President Obama signed HR 3590, the
Patient Protection and Affordable Care Act
into law on March 23, 2010. The President
also signed HR 4872, the Health Care and
Education Reconciliation Act, into law on
March 30, 2010. The two Acts combined
are collectively referred to as the
Affordable Care Act (ACA) or federal
health care reform.
Individual Mandate
The ACA requires most individuals to
have health insurance or health coverage
beginning January 1, 2014. Health
insurance can be through an employer or
individual health plan. Health coverage
can be through programs such as
Medicare, Medicaid, Florida Healthy Kids,
Tri-Care, federal employee health benefit
plans, veteran’s health care, or Indian
Health Services (IHS).
If you already have coverage, you do not
need to do anything unless you receive a
notice from your insurer that your health
insurance does not qualify as “Minimum
Essential Coverage”. If you receive this
notification, you should contact the federal
Marketplace at 1-800-318-2596, visit
www.healthcare.gov, or contact a licensed
agent or broker for assistance. If the
insurer provides a designated number to
contact for assistance, you should contact
that number if you have questions about
the notice.
There are several exceptions to the
individual mandate and some of these
exceptions are shown below:
Individuals that are at or below 100% of
the federal poverty level and would have
been eligible for Medicaid Expansion as
outlined in the ACA if the State of
Florida had participated in the
expansion.
Individuals that are members of qualified
health care sharing ministries or a
religion that is opposed to accepting
health insurance benefits.
Individuals that are not lawfully in the
United States.
Members of a federally-recognized Indian
tribe.
Individuals for whom coverage would be
unaffordable as determined by the federal
Department of Health and Human Services.
Individuals that are incarcerated.
Individuals that do not have health coverage
and who are not exempt from the federal
requirement may be subject to a Shared
Responsibility Payment collected by the
Internal Revenue Service (IRS).
If you have questions about your particular
situation, call the Marketplace at 1-800-3182596 to find out if you are required to
maintain health coverage.
You can contact the Florida Department of
Children and Families (DCF) directly at
http://www.myflorida.com/accessflorida/ or
call 1-866-762-2237 if you think you may
qualify for Medicaid.
You may contact Florida Healthy Kids
directly in order to find out about health
insurance for children between ages 5 and
18 at 1-888-540-5437 or by visiting their
website at https://www.healthykids.org/.
8
Plans Available
As of January 1, 2014, all coverage
will be guaranteed issue, which
means you cannot be turned down
due to your health history. Preexisting conditions will be covered
and the insurer cannot charge you
more because of a health condition.
Only four rating factors can be used
to determine your premium:
Age
Individual or family coverage
Where you live
Whether or not you use tobacco
There are four categories of plans
(Bronze, Silver, Gold, and Platinum),
plus a separate catastrophic plan for
certain qualifying individuals that will
be offered through the Marketplace.
Each category of plan will offer the 10
Essential Health Benefits (EHB) as
required by federal law. The plan
benefits, premiums, provider network
availability, and enrollee out-of-pocket
expenses will vary depending on the
plan chosen. Plans will cover 60 to 90
percent of the medical expenses,
depending on which plan you select.
Catastrophic plans will be available to
people under age 30 or for those
suffering a financial hardship as
determined by the federal Department
of Health and Human Services (HHS).
These plans carry high deductibles
equivalent to the out of pocket
maximum, or $6,350 for a single
person, in 2014. You cannot apply tax
credits to these plans, either.
All plans sold or renewed in 2014
must limit the out-of-pocket exposure
of consumers to $6,350 for individuals and
$12,700 for families of two or more. The
deductible for small group plans will be
limited to $2,000 for self-only coverage and
$4,000 for family coverage in 2014. Both
types of plans will have the deductible
indexed to average premium growth in
future years.
Coverage Levels
All plans must design their cost-sharing
(deductibles, co-insurance, and copayments) to fit into specific levels of
coverage. The levels of coverage are
defined as follows:
Bronze Level – The plan must cover
60% of expected costs for the average
individual
Silver Level – The plan must cover 70%
of expected costs for the average
individual
Gold Level – The plan must cover 80%
of expected costs for the average
individual
Platinum Level – The plan must cover
90% of expected costs for the average
individual
The Marketplace will group coverage by
these “metal” levels, allowing you to easily
evaluate comparable options. The higher
the metal level means the insurer will pay a
higher portion of your claims should you
need medical services. You need to pay
close attention to the out of pocket
expenses and provider network available for
all plans when reviewing your options. Keep
in mind your particular preference when
deciding if you want to pay more in premium
and have lower out of pocket costs or pay a
lower premium and be prepared to pay
more out of pocket if medical services are
needed.
9
HER HEALTH-RELATED
Required Benefits
All insurers that participate in the
Marketplace will be required to provide a
package of Essential Health Benefits (EHB)
in order to assure that the comparisons are
“apples-to-apples”. The law also requires
that insurers and health benefit plans
offered by employers cover mental health
and addiction services on an equal footing
with other medical coverage. Insurers will
also be required to offer specified wellness
and preventive services at no out-of-pocket
cost to patients.
Every non-grandfathered health plan sold or
renewed in the individual and small group
market on or after January 1, 2014, whether
purchased through the Marketplace or not,
must include all the following Essential
Health Benefits (EHB):
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance abuse
disorder services, including behavioral
health treatment
Prescription drugs
Rehabilitative and habilitative services
and devices
Laboratory services
Preventive and wellness services and
chronic disease management
…
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