Health and Disability Insurance

Chapter 11
Health and Disability

Insurance
McGraw-Hill/Irwin Copyright © 2007 by The McGraw-Hill Companies, Inc. All rights reserved.
Health Care Costs
• The US has the highest per capita medical

expenditures of any industrialized country
in the world.
 $7,761 health care costs per person in 2005.
 This amount is twice as much spent on health
care as the average for the 24 industrialized
countries in Europe and North America.
 Medical expenditures were 6% of the GDP in
1965, but rose to 16% of our GDP in 2005 and
are predicted to be 17% in 2011.
11-2
Why Does Health Care Cost So Much?
• High administrative costs.

 26% of health care dollar vs. 1% in Canada.
• Use of sophisticated, expensive technologies.
• Duplication of tests and technologies.
• Increases in the variety and frequency of
treatments.
• Increasing number and longevity of elderly
people.
• Regulations that result in cost shifting rather
than cost reduction.
11-3
Why Does Health Care Cost So Much?
• Increasing number of accidents, crimes that

require emergency services.
• Limited competition, restrictive work rules in
the health care delivery system.
• Labor intensiveness, rapid earnings growth for
health care professionals.
• Innovative treatments for AIDS, cancer.
• Built in inflation in health care delivery system.
• Malpractice Insurance.
• Aging baby boomers
11-4
What is Being Done About the High
Costs of Health Care?
• Careful review of fees and charges.
• Establish incentives for...
 Preventive care.
 Services provided out of the hospital where
medically acceptable.
• Involve community in balancing health care
needs, health care resources.
• Encourage prepaid group practices.
• Support community health education
programs so people take better care of
themselves.
11-5
What Can You do to Reduce Your
Personal Health Care Costs?
• Stay well - focus on prevention.
 Eat a balanced diet, keep your weight under
control.
 Avoid smoking, don’t drink to excess.
 Get enough rest, relaxation, and exercise.
 Drive carefully, watch out for accident and fire
hazards in the home.
11-6
Health Insurance and
Financial Planning
• 45 million Americans have no health
insurance.
• An older student population is not covered by
their family’s policy. 40% are older than age
25.
• Health insurance limits the financial burdens
people suffer due to illness or injury.
• It’s part of your overall risk management plan
to safeguard your family’s economic security.
 Disability income insurance protects your most
valuable asset - your ability to earn an income.
11-7
Financial Planning (continued)
• Group plans comprise more than 90% of all

health insurance.
• Most group plans are employer sponsored;
employer pays part or most of the cost.
• 1996 Health Insurance Portability and
Accountability Act provides federal portability
standards, nondiscrimination in health
insurance, and guaranteed renewability.
 If you changes jobs you need not lose your health
insurance.
• Individual insurance is also available.
11-8
Financial Planning (continued)
• You can supplement your group policy.

 The coordination of benefits provision in a
policy says that benefits received from all
sources are limited to 100% of allowable
medical expenses.
• COBRA requires many employers to offer
employees and dependents the option to
continue their group coverage for a set
period of time following a divorce.
11-9
A Good Health Insurance Plan Should..
• Offer basic coverage for hospital and doctor bills.

• Cover at least 120 days hospital room and board.
• Provide at least $1,000,000 lifetime maximum for
each family member.
• Pay at least 80% of out-of-hospital expenses after
yearly deductible of $500-$1,000/person is met .
• Impose no unreasonable exclusions.
• Limit your out-of-pocket expenses to no more
than $3,000 to $5,000 in a year, excluding dental,
optical, and prescription costs.
11-10
Types of Health Care Coverages
• Basic includes…
 Hospital expense insurance.
• Hospital room and board and other charges.
 Surgical expense insurance.
• Surgeon's fee for an operation.
 Physician expense insurance.
• Pays for physician’s care that does not include surgery,
such as office visits, lab tests and X-rays.
11-11
(continued)
• Major medical expense insurance.

 Covers expenses for a serious injury or long-term
illness. Has a deductible, coinsurance, and a stop-
loss provision.
• Comprehensive major medical insurance.
 Low deductible offered without a separate, basic
plan. Covers hospital, surgical, and other bills.
• Dread disease and cancer insurance
policies.
 Focus on unrealistic fears, and only pays out for
very specific conditions. Often sold by people
working on commission. Poor value.
11-12
(continued)
• Hospital indemnity.
 Pays a fixed amount for each day you are in a
hospital. Best for people in high-risk groups.
• Dental expense insurance.
 Covers exams, cleaning, x-rays, fillings, root
canals, and oral surgery.
• Vision care.
 Exams, contact lenses, and glasses.
• Long term care insurance.
 Growing faster than any other form of
insurance.
11-13
Health Insurance Policy Provisions
• Eligibility.
 Varies with age, marital status,
and dependency.
• Assigned benefits.
 Insurance pays your doctor or hospital directly.
• Internal limits.
 Fixed amount per day for a hospital room.
• Copayment.
 Cost sharing in the form of a flat dollar amount
you pay, such as $15.00 per office visit or $10
per prescription.
11-14
Health Insurance Policy Provisions
(continued)
• Service benefits vs. fixed $ amount

• Benefit limits - maximum $ amount or
maximum # of days in the hospital.
• Exclusions and limitations.
• Coordination of benefits - coverage under
more than one policy.
• Guaranteed renewable.
• Cancellation and termination - explains the
circumstances.
11-15
Trade-Offs in Choosing a Policy
• Reimbursement versus indemnity.
• Inside limits versus aggregate limits.
• Deductibles and coinsurance.
• Out-of-pocket limit, or stop-loss.
• Benefits based on reasonable and
customary charges.
• Health information online can
provide information when you are
comparing policies.
11-16
Private Sources of Health
Insurance and Health Care
• Private insurance companies.
 Individual policy.
 Group policy sold to an employer.
• Hospital and medical service plans.
 Blue Cross - hospital care
benefits.
 Blue Shield - surgical and
medical services benefits.
 Managed care.
• Prepaid health plan.
• Primary care physician.
11-17
Types of Managed Care
• Health Maintenance Organization.

 Contracts with selected care providers.
 Fixed pre-paid monthly premium.
 Focus is on prevention and wellness.
 Basic and supplemental services.
• Preferred Provider Organization.
 Several providers to choose from.
 Costs more than a HMO, but you have more
choices, fewer restrictions.
 If you go to a non PPO provider, you pay more.
11-18
Government Health Care Programs
• Medicare - federal program for those age

65 and older, and certain disabled persons.
 Part A - compulsory.
- Covers hospital costs including doctor
 Part B - voluntary if have proof of coverage.
- Doctor’s visits and prescriptions
 Parts C & D – Medicare +Choice Plan
• Medigap - may pay what Medicare doesn’t.
• Medicaid.
 Low income people of all ages.
 State administered with federal guidelines.
11-19
Medical Websites
• www.nlm.nih.gov
• www.drugdigest.org
• www.mayoclinic.com
• www.oncolink.com
• www.nimh.nih.gov
• www.nationalhealthcouncil.org
11-20
Long Term Care ?’s
• Maximum Daily benefit?
• How long does coverage last?
• Maximum policy limit?
• Elimination period?
• Coverage if you stay at home?
• Insurer safety?
11-21
Disability Income Insurance
and Financial Planning
• Disability is more likely than death at
any age.
• Young, healthy people don’t think about
risks related to all their future earning
potential.
• Provides regular cash income lost as
the result of an accident, illness or
pregnancy.
• If you become disabled your income
drops but your expenses go up.
11-22
Disability Income Insurance
and Financial Planning (continued)
• Carefully read a policy’s definition of disability.

 May only pay if you can’t work at any job.
 Look for a policy that pays if you are unable to work
at your regular job.
• Aim for a benefit that when added to your other
income will equal 60-70% of your gross pay.
• How long do benefits last? To age 65? For
life?
• How long is the waiting period? 30 days? 90
days?
• Look for a policy that is both noncancelable
and guaranteed renewable.
11-23
Four Sources of Disability Income
• Employer
 Group disability policy may be short or long
term.
• Social Security.
 Covers total disability that lasts more than
twelve months.
• Workman’s Compensation.
 If you are injured at work or your injury is a
result of your type of employment.
• Disability insurance.
 Benefits limited to 70-80% of your take home
pay.
11-24

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Chapter 11

Health and Disability

• The US has the highest per capita medical

• High administrative costs.

• Increasing number of accidents, crimes that

• Group plans comprise more than 90% of all

• You can supplement your group policy.

• Offer basic coverage for hospital and doctor bills.

• Major medical expense insurance.

• Service benefits vs. fixed $ amount

• Health Maintenance Organization.

• Medicare - federal program for those age

• Carefully read a policy’s definition of disability.

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