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COURSE OVERVIEW
The Introduction to Health Insurance course covers the fundamentals of health insurance, which will be new for many consumers. It explains how health insurance works, how the ACA aims to decrease health insurance costs, and the rules that govern health insurance in the state of California.
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COURSE OBJECTIVES
Define health insurance and describe the different types of health insurance plans
Understand how insurance works and the value of having health insurance
Understand how the ACA aims to decrease health insurance costs Describe the rules that govern health insurance including the California Health Insurance Code and the Knox-Keene Act
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OVERVIEW In this lesson we will focus on the basics of health insurance, how it works and the value health insurance brings to individuals and families. OBJECTIVES: Define health insurance and describe the different types of health insurance plans Understand how insurance works and the value of having Click to edit Master title style health insurance
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Preventive care and wellness services are covered by health insurance with no out-of-pocket cost. to edit Master title style InsuranceClick provides protection from overwhelming medical costs arising from chronic illness or injuries.
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MANAGED CARE
In the U.S., the majority of health plan products offered both privately and publicly are managed care plans.
Networks of doctors and hospitals are created by the insurance company to provide quality care and predictable costs.
Providers in-network contract with the insurance company to coordinate care, providing services at negotiated rates. Some plans employ their doctors and staff.
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MANAGED CARE
In addition Insurance companies help to ensure that health services are medically necessary and helpful to the patient. Some procedures require prior approval. Most plans offer educational programs. Insurers must provide access to quality providers (doctors and hospitals), including specialists, within a certain timeframe. Doctors and hospitals must attain certain standards to be included in Click to edit Master title style the network. Negotiated agreements between insurers and providers set standards to maintain credentials, meet availability requirements, etc.
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Unlike an HMO
o The member does not generally need a referral from a PCP to receive care in-network. o Members are free to seek care directly from any network doctor or Click to edit Master title style hospital
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IMPORTANT TERMINOLOGY
Balance Billing Coinsurance Copayment Cost-Sharing Deductible Out-of-Pocket Limit
To find a comprehensive list of definitions look to the Glossary of Terms job aid and at:
www.coveredca.com/glossary.html or www.healthcare.gov/glossary/index.html
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The member is responsible for a cost-sharing contribution determined by the level of coverage (or benefit design) offered by the plan.
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Monthly premium = $200 Deductible = $5,000 Coinsurance = 20 percent Out-of-pocket limit = $6,000 Click to edit Master title style and incurs $50,000 in Ann is in a serious home repair accident covered medical expenses.
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OVERVIEW This lesson will focus on the positive impact the ACA will have on health insurance in California, including cost, access and quality. This lesson will also describe the regulations for health insurance in California. OBJECTIVES: Understand how the ACA aims to decrease health insurance costs, improve access to care and quality. Click to edit Master title style health insurance including Describe the rules that govern the California Insurance Code and the Knox-Keene Act.
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With more insured members paying in, the risk of catastrophic illness and its costs are spread over a larger group.
Individuals and families no longer risk personal financial calamity leading to bankruptcy due to catastrophic injury or illness. Formerly uninsured individuals will be able to seek preventive care or treatmentClick sooner, avoiding serious illness and higher costs. to edit Mastermore title style
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PREVENTIVE CARE
Health problems can be identified earlier, managed more effectively and treated before they become more serious.
Preventive services are not only cost-effective, but also sometimes life-saving.
Out-of-pocket costs will no longer act as a barrier to keep members from seeking recommended screenings, counseling, immunizations, etc. This means better health outcomes as well as lower health care costs. Click to edit Master title style
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Health insurance companies must meet rules relating to affordability, required benefits and market standards with standardized benefit options that are easy to compare.
Covered California will increase the number of individuals with insurance from plans and providers that provide the best value. Health insurance companies competing Click to edit Master title style for business will lead to lower rates, better customer service and higher quality.
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TWO GOVERNMENT AGENCIES REGULATE HEALTH INSURANCE IN CALIFORNIA California Department of Insurance (CDI) Department of Managed Health Care (DMHC)
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Enforce the laws and regulations of either the Insurance Code (CDI) or the Health and Safety Code (DMHC)
Enforce the Affordable Care Acts reforms and new market rules such as guaranteed issue for all individuals seeking coverage, Essential Health Benefits requirements, medical loss ratio rules, no cost-share for preventive services, standard plan values.
Click to editrenewability Master title style Enforce guaranteed of coverage and termination rules.
Enforce fair claims payment and processing rules.
Enforce the states mental health parity requirements.
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o Oversight of health plan operations (e.g., evaluation of a health plans networks, provider agreements, subcontractor relationships)
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A traditional indemnity health insurance product ( PPO or EPO) is subject to oversight by the CDI
Plans sold in the Covered California marketplace are always subject to government regulations but are also subject to Covered Californias regulations and the terms of the plans contract with Covered California, which may be stronger than the applicable Click to edit Master title style regulation. Covered California is not a regulator but is charged with creating a robust, organized health insurance marketplace.
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COURSE SUMMARY
You should now be able to: Define health insurance and describe the different types of health insurance plans and products Understand how insurance works and the value of having health insurance
Understand how the ACA aims to decrease health insurance costs, improve access and quality and protect consumers
Describe the general rules that govern health insurance found in the California Insurance Code and the Knox-Keene Act
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