VA’S OF THE FUTURE
I N S U R A N C E
VERIFICATIONS
SEPTEMBER 2023
VA’S OF THE FUTURE
Why do you need health insurance in the
U.S.?
•In the U.S., unlike most of the world, health insurance is privatized
•Seeking medical treatment for illnesses or accidents would be very expensive without health
insurance
•Health insurance offsets the cost of doctor bills, surgery, hospital, laboratory and x-ray fees, and
pharmacy costs
VA’S OF THE FUTURE
Why do you need health insurance in the
U.S.?
Healthcare costs continue to increase.
Even with insurance, consumers are asked to pay a larger amount of healthcare costs.
40% of US citizens are uninsured One of the largest age groups uninsured is young people
between the ages of 20 and 29
Health care reform is currently underway in the United States. Visit [Link] for more
information.
VA’S OF THE FUTURE
How can insurance companies afford to pay
healthcare costs?
They pick groups to insure which are statistically healthy.
They set limitations on coverage.
They negotiate with healthcare providers to discount their charges.
They charge the consumer premiums, deductibles, and co-pays.
VA’S OF THE FUTURE
Vocabulary
Deductible
Co-pay
Premium
Pre-existing condition
Out of pocket expense
Schedule of benefits
Provider and subscriber
HMO
PPO
Point-of-Service
In-network provider vs. out-of-network provider
VA’S OF THE FUTURE
Deductible
The amount you pay before your insurance starts to pay.
In general, the higher your deductible, the lower the premium
VA’S OF THE FUTURE
Co-Pay
A fixed amount the subscriber pays at the time of service (when you go to the doctor).
The amount may differ depending on the type of doctor you visit (general practitioner vs.
specialist) There are co-pays for doctor’s as well as for prescription medications.
VA’S OF THE FUTURE
What is a premium
Premium - the monthly fee that is paid to an insurance company or health plan to provide health
coverage, including paying for healthrelated services such as doctor visits, hospitalizations, and
medications.
VA’S OF THE FUTURE
Pre-existing condition
An illness or injury which happened before you purchased your insurance policy.
Examples of pre-existing conditions are: Diabetes Cancer Tendonitis from a 10-year-old ski
injury Pregnancy (yes, pregnancy is considered a preexisting condition)
Affordable Care Act: Beginning in 2014, health insurance companies cannot deny you for having
a pre-existing condition.
VA’S OF THE FUTURE
Provider and Subscriber
Provider The insurance company
Subscriber You –
When you call a doctor to schedule an appointment, the receptionist will ask, “Who is your health
insurance provider” and you will respond “Blue Cross/Blue Shield” or “United”
VA’S OF THE FUTURE
Out-of-pocket expense
Medical costs which the subscriber (YOU) is responsible for. These are in addition to the cost of the
premium. They are charges the insurance will not cover (e.g., deductible, co-pays, etc)
VA’S OF THE FUTURE
Schedule of Benefits
A listing of the services for which payment will be made by a third party without specification of
the amount to be paid.
Make sure you read this carefully when choosing a policy & consider what your medical needs are
or might be.
VA’S OF THE FUTURE
In-network provider vs. out-of network
provider
In-Network - A healthcare provider or facility that has a contract with the insurance company.
They provide services at a reduced cost to subscribers of that insurance company
Out-of-Network - A healthcare provider or facility that does not have a contract with the
insurance company. Treatment at these facilities will cost the patient more.
VA’S OF THE FUTURE
Types of Insurance Policies
Managed Care:
Preferred Provider Organizations (PPOs)
Health Maintenance Organizations (HMOs)
Others
Fee-for-Service / Indemnity Plans
Point-of-Service Plan
Commercial Plans
VA’S OF THE FUTURE
HMO – Health Maintenance Organization
You will be assigned a general practitioner
That GP will determine if and when and to whom you will go if more specialized treatment is
necessary (serves as a gatekeeper)
You may receive a list of PCPs (Primary Care Providers) from which to choose a doctor (based
on location, gender, etc.)
Typically with the HMO, no deductible is charged There may be a small co-pay fee for
visiting a doctor in-network
VA’S OF THE FUTURE
PPO – Preferred Provider Organization
Patient may see any doctor on list of PCPs (Primary Care Providers)
Patient may visit specialist without referral from a GP
May pay greater co-pay, deductible, and likely more out-of-pocket expenses
VA’S OF THE FUTURE
Fee-for-Service (Indemnity) Plan
Obtained by individuals on their own, or through groups, such as employers or associations.
Generally offer the freedom to choose your own healthcare providers including specialists and
hospitals.
The medical costs are split between the insurance company and the subscriber. Each pays a
fixed percentage of the medical costs.
These plans have set maximum “out-of-pocket expenses” the subscriber will have to pay.
VA’S OF THE FUTURE
Point of Service Plans
A blend of elements of managed care and indemnity plans.
Every plan is different, so choose carefully!
Read the fine print and understand the terminology.
If you have a pre-existing condition, or if you have regularly prescribed medications (birth
control, anti-depressants, blood pressure, insulin, etc.) make sure costs for those will not be
exorbitant