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Forms of Insurance
Since
1992, there has been a strong move to contain the spiraling costs
of health care. Today, health insurance is offered in three major
formats:
Third Party Payors, Health
Maintenance Organization (HMO), and Preferred
Provider and Point of Service Organizations (PPO/POS)
There are three government-funded
health insurance plans that it is important for the person
with a SCI/D to know and understand:
Medicare
Medicaid
Social Security Disability Insurance (SSDI)
Major Health Insurance Formats
- Third Party Payors - Insurance companies or organizations that sell commercial
insurance to employers, process claims, and pay providers. There are two categories:
- “Fee for service” (traditional kind of health care policy) pays providers a
fee for the services provided to the insured; offers consumers the most
choices of doctors and hospitals. In most cases, the insurance covers 80%
of the charge and the patient pays the remaining 20% coinsurance.
- Managed Care Organization (MCO) – A payor organizes a group of
providers, called a network, who have agreed to provide specified health
services to persons who enroll in the MCO plan. The network providers
are paid according to a predetermined, contracted rate. (Because of lower
costs to employers, MCOs have almost entirely replaced the indemnity
“fee for service” plans in the U.S.)
- Health Maintenance Organization (HMO) These are prepaid health
plans for which there are several existing models; the major differences
in the models exist in the relationship between the HMO and the participating physicians.
You or the insured, the HMO member, pay(s) a monthly premium. In exchange,
the HMO provides comprehensive care for you and your family, including
doctors' visits, hospital stays, emergency care, surgery, lab tests, x-rays,
and therapy. The HMO arranges for this care; usually, your choices of doctors and
hospitals are limited. However, exceptions are made in emergencies or when medically necessary.
- Preferred Provider and Point of Service
Organizations (PPO/POS) These are
mixed model plans that blend a combination of MCO and HMO features. A PPO,
similar to an HMO, has a limited number of doctors and hospitals from which to
choose and requires that you choose a primary care doctor to monitor your health
care. A POS offers a broader selection of providers; the insured selects the
provider of choice when the medical services are needed. When you use
PPO/POS providers (sometimes called "preferred" providers,
other times called"network" providers), most of your
medical bills are covered. Usually there is a small co-payment for each visit; for some services, you may
have to pay a deductible and a co-payment. If you choose (a) provider(s) outside of the
network, coverage payment may be less and you may pay a larger deductible or
co-payment. Covered services most often included preventive care such as visits
to the doctor, well-baby care, immunizations, and mammograms.
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Government-Funded Health Insurance Plans
There are three government-funded health insurance plans that it is important for the
person with a SCI/D to know and understand:
- Medicare 1 a
federal health insurance program for persons who are disabled
and have received Social Security Disability Insurance (SSDI)
for at least 24 months, and for persons 65 years of age or older.
Medicare has two parts; these do not cover the same things:
- Part A covers inpatient hospitalization, skilled nursing facility care, and
hospice care. It will pay for some home health care services, however,
you must need skilled care and be homebound. Most people don't have to
pay premiums for Part A coverage, but you will have deductibles to pay.
- Part B covers inpatient and outpatient physician services, as well as
outpatient therapies, limited medical supplies and medical tests, and some
durable medical equipment (DME). (DMEs require a Certificate of
Medical Necessity (CMN) submitted by your physician) Part B is
optional, requires a monthly premium, an annual deductible, a copayment
for each visit or service.
- Medicaid is a federal program that is administered by the states.
It provides medical assistance for persons with low-income and
limited assets. Medicaid covers inpatient and outpatient hospital
care, physician services, home health care services, medications,
and some supplies.
- Social Security Disability Insurance (SSDI) [www.ssa.gov/applyforbenefits]
is for one who is permanently disabled; eligibility is based
on one’s prior work
history under Social Security and determined by the Social Security
Administration.
- If you are permanently disabled and have been receiving SSDI benefits
for 24 months, you will then be automatically enrolled in Medicare
- Please note: SSI is
not an insurance program.
SSI disability payments are made on the basis of financial need. SSI
recipients are automatically enrolled in Medicaid, i.e. State Medical
Assistance. There are several differences in the eligibility rules for SSI
and SSDI.2
Inquire about your eligibility for Medicare/Medicaid as soon as possible following
your injury. If you are still in acute rehabilitation, seek the assistance of your social
worker or discharge planner. Begin the application process immediately. The
approval process is lengthy; periodic inquiries to determine status of the application is
appropriate and encouraged.
1 Understanding the Benefits, p. 24. Social Security Administration,
Publication No. 05- 10024, January 2000
2 Disability Benefits, p. 1. Social Security Administration, Publication No. 05-10029,
September 1999
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Consumer Rights
Forms of Insurance
Selecting a Policy
Insurance Maze
Are You Uninsured?
Resources
Download Booklet PDF
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Insurance
Guide
