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Presented by:

Grace Blankenhagen
Stephanie Larson
Ashley Lopez
Danielle Weaver
Health Insurance Terms
Allowable costs Items/elements that are reimbursable
under a payment formula may exclude uncovered services

Co-payment A fixed amount (ex: $15) you pay for a covered

health care service, usually when you receive the service

Deductible The amount you owe for health care services

your health insurance or plan covers before your health
insurance begins to pay
E.g. If your deductible is $1000, your plan wont pay anything until
youve met your $1000 deductible.
Health Insurance Terms
Co-insurance Your share of the costs of a covered health
care service calculated as a percentage of the allowed
amount for the service

Premium The amount that must be paid for your health

insurance/plan can pay it monthly, quarterly or yearly

Health Saving Account (HSA) A personal saving account

that allows participants to pay for medical expenses with
pre-tax dollars
How You and Your Insurer Share Costs
Different Health Insurance Policies
Group Health Insurance Individual Health Insurance
A coverage plan offered by Health insurance plans
an employer or other purchased by individuals
organization that covers to cover themselves and
individuals in that group their families
and their dependents
under a single policy
Different Health Insurance Policies
Health Maintenance Preferred Provider
Organization (HMO) Organization (PPO)
A form of managed care that A form of managed care in
provides comprehensive which the member has more
health care services for flexibility in choosing
enrollees in a particular physicians and other
geographic area and require providers (can see both
the use of specific, in- participating and
network providers nonparticipating providers)
There is an out-of-pocket
expense if members see a
non-participating provider.
Different Health Insurance Policies
Medicaid Medicare
Health insurance program Federal health insurance
created in 1965 that provides program that provides health
health benefits to low-income benefits to Americans 65+
individuals who cannot afford Includes Part A (covers
Medicare or other hospital services) and Part B
commercial plans (covers doctor services)
Funded by federal and state PT is a mandatory benefit -
governments outpatient PT must meet the
Many State Medicaid Plans definition of skilled
include PT as an optional services
Private Insurance - Blue Cross Blue Shield
(Sandstrom et al, 2013)

In 2009, 54% of therapy expenditures for patients less than 65 years of

age were funded by private insurance.

In 2011, 70% of employment-based private insurance plans stated that

PT was an included benefit.
Nearly all of the plans had placed some limit on PT benefits.
Most common was a limit of 20, 30, or 60 visits per year.

BCBS Largest provider of private insurance in the United States, 39

plans studied across the Midwest
PT benefits were included in all 39 insurance plans studied.
PT benefits were often combined with other disciplines (most often
OT, SLP, or Chiropractic Therapy) in 29/39 plans
Most common combination was PT, OT, SLP
Average visit limit was 21.5 visits/year (in the Midwest, average visit
limit 16.5 visits/year)
Medicare Plans
Part A (Hospital Insurance) Part B (Medical Insurance)
Coverage Includes: Coverage Includes:
Hospital stays Medically necessary services
Skilled care facility stays Preventative care
Nursing home care Clinical Research
Hospice Ambulance services
Home health services Durable Medical Equipment
Mental health
2nd opinion prior to surgery
Some prescription drugs
Medicare Plans Cont.
Part C (Medicare Advantage Plan)
Coverage Includes:
Original Medicare benefits
Part D (most include this)
Some offer additional coverage for vision, dental, hearing
and/or wellness programs

Part D (Prescription drugs)

Cost of Medicare
Most people over 65 qualify for premium-free Medicare if
Paid Medicare taxes while working
Already receive retirement benefits from Social Security or Railroad
Are eligible for Social Security or Railroad benefits but havent filed
for them
Patient or spouse had Medicare-covered government employment

If they do not meet the above requirements, there is a monthly

premium for Medicare
Part A = $411/month
Part B = $121.80/month
Part C = based on plan
Part D = based on plan
*Prices subject to change based on income
Secondary Insurance
The patient has two insurance plans, generally
Medicare and another health insurance plan.

One plan is the designated primary payer, the other is a

secondary payer.

Primary will pay up to the limits of its coverage, and

secondary payer will generally cover the rest (or most).
Medicare Therapy Cap
PT & SLP services are combined
Cap limit = $1,960 (estimated $1,980 for 2017)

OT services
Cap limit = $1,960 (estimated $1,980 for 2017)

Services are covered for patients who have Part B until the
amount paid by both the patient and Medicare reach the cap
limit. Patients pay 20%, including the Part B deductible.

Cap limits can be expanded if there is medically necessity based

on documentation for further outpatient services.
These are called thresholds
$3,700 for PT & SLP combined
$3,700 for OT
Medicaid Coverage
For those who qualify, coverage is based on Mandatory
and Optional Benefits.
Mandatory benefits: required by the federal government
to be paid for and covered
Optional benefits: left up to each state to decide on
whether or not to pay for
Mandatory & Optional Benefits
Optional Benefits Cont.
Costs of Medicaid
States can choose to charge premiums to establish cost
sharing, which can include charges such as co-payments
and deductibles on services. These costs have limits on the
maximum value the state can charge, and some people can
be charged more based on their incomes.

Children and pregnant women are exempt from out of

pocket costs.
Is PT Covered?
PT is an optional benefit
Michigan covers physical therapy services
Defining Obamacare
(Patient Protection and Affordable Care Act of 2010)
The Affordable Care Acts core achievement is to make all
Americans insurable, by requiring insurers to accept all
applicants at rates based on population averages regardless
of health status.

Medicaid expansion to low income housing

Cover individuals close to poverty line

Subsidizing private insurance

Allows for people who are not on their employers plan
Before ACA

Image from: Hall, 2014

Deadlines for Enrollment for 2017 Coverage
November 1, 2016: Open Enrollment started first day to
enroll, re-enroll, or change a 2017 insurance plan through the
Health Insurance Marketplace. Coverage can start as soon as
January 1, 2017.

December 15, 2016: Last day to enroll in or change plans for

coverage to start January 1, 2017.

January 1, 2017: 2017 coverage starts for those who enroll or

change plans by December 15.

January 31, 2017: Last day to enroll in or change a 2017 health

plan. After this date, you can enroll or change plans only if you
qualify for a Special Enrollment Period
Goals of Obamacare
Make healthcare affordable, accessible, and high
quality for:


Image from:

Timeline Healthcare Law
2010: Patients Bill of Rights
Protects from insurance abuse
Full coverage preventive visits

2011: Medicare
Free preventive services
50% discount for those in the donut hole for brand-name drugs

2012: Accountable Care Organizations

Help promote collaborative effort between health care providers

2013: Open Enrollment

Open enrollment for the Health Insurance Marketplace

2014: Full Access

All Americans will have affordable access to insurance
Tax credits to mid-low income families
Expansion of Medicaid to cover low-income individuals
Current and Projected Problems
With the Affordable Care Act
There have been yearly climbs in premium costs, and these
increases are projected to continue.
If you choose a low premium plan, you are likely to have a
very high deductible.
E.g. In 2015, the average deductible for Silver plans was $2,500
and for Bronze plans it was $5,300.

There has been a decrease in the number of participating

insurance companies.
This reduces competition between insurance companies,
resulting in higher premiums.

The federal government has had to increase its spending for

health programs such as Medicaid/Medicare and the ACA.
Current and Projected Problems
With the Affordable Care Act
The middle class (those making less than $200,000/year)
are projected to get heavily taxed as further laws associated
with the ACA take into effect.

Future cuts to Medicare are projected to limit seniors

access to medical services.

Provider capacity and patient access puts a strain on

primary care providers (PCPs) due to the large number of
new patients seeking care.

Many believe the ACA infringes on personal rights and

religious freedoms.
When President-Elect Donald Trump and
the Republican-majority Congress take
office in January, it is likely there will be
changes made to the healthcare system.

President-Elect Trump has a 7-point plan

to reform our current healthcare system.
Possible Changes to the Healthcare System
1. Repeal Obamacare.
No one will be forced to buy health insurance.

2. Allow insurance companies to sell in any state as

long as the plans are concurrent with each states
Current laws prevent insurance companies from selling
to consumers in other states.
The theory: With more competition taking place
between the companies, the costs for insurance will
Possible Changes to the Healthcare System
3. Allow those with insurance to claim their
premium health insurance payments as
exemptions on their taxes.
Review Medicaid requirements as well.
The theory: Anyone who wants insurance will be able to
get it. They will not be limited by their ability to afford it.

4. All healthcare providers will make the prices of

their services known.
This will allow people to shop around to find the best
prices for their medical needs.
Possible Changes to the Healthcare System

5. Establish tax-free Health Savings Accounts

People will be able to set up these accounts for
themselves and their families.
Money placed into the accounts will accumulate to be used in
times of need.
As part of a persons estate, it will pass on to their family
members if the person passes away.
Possible Changes to the Healthcare System

6. Allow the states to manage Medicaid instead of

the federal government.
Incentives will be provided to the states to encourage the
elimination of fraud, waste, and cases of people abusing
the system.
The theory: States better know the needs of their
people, and many states already offer more
individualized benefits as part of their Medicaid
Possible Changes to the Healthcare System

7. Allow free markets for pharmaceutical

Medications that may be safer, cheaper, or more reliable
could then be imported into the country.
The theory: This will give consumers more options for
where they get their medications.
The increased competition may also help control drug prices.
Glossary of health coverage and medical terms website. Accessed December 8, 2016.
2. Sandstrom RW, Lehman J, Hahn L, Ballard A. Structure of the physical-therapy benefit in a typical Blue Cross
Blue Shield preferred provider organization plan available in the individual insurance market in 2011. Phys Ther.
2013; 93: 1342-1350.
3. Hall MA, Lord R. Obamacare: what the Affordable Care Act means for patients and physician. BMJ.
2014;349:g5376. doi: 10.1136/bmj.g376
4. Dates and Deadlines for 2017 Health Insurance. Health Care website.
guide/dates-and-deadlines/. Accessed December 8, 2016.
5. Assistant Secretary for Public Affairs. Key features of the affordable care act. Health Care
website. November 18, 2014.
Accessed December 8th, 2016.
6. Assistant Secretary for Public Affairs. Key features of the affordable care act by year. Health Care website. August 13, 2015.
Accessed December 8, 2016.
7. Year Six of the Affordable Care Act: Obamacares Mounting Problems. The Heritage Foundation. Robert E. Moffit.
Published April 1, 2016. Accessed December 3, 2016.
8. What Part A covers. The Official U.S. Government Site for Medicare. Accessed December 2, 2016.
9. What Part B covers. The Official U.S. Government Site for Medicare. Accessed December
2, 2016.
10. Medicare Advantage Plans cover all Medicare services. The Official U.S. Government Site for
cover-all-medicare-services.html Accessed December 2, 2016.
11. What drug plans cover. The Official U.S. Government Site for Medicare. Accessed December 2, 2016.
12. Part A costs. The Official U.S. Government Site for Medicare.
medicare-costs/part-a-costs/part-a-costs.html Accessed December 4, 2016.
13. Part B costs. The Official U.S. Government Site for Medicare.
medicare-costs/part-b-costs/part-b-costs.html Accessed December 4, 2016.
14. Costs for Medicare Advantage Plans. The Official U.S. Government Site for Medicare.
plans.html Accessed December 4, 2016.
15. Costs for Medicare drug coverage. The Official U.S. Government Site for Medicare. Accessed December 4, 2016.
16. How Medicare works with other insurance. The Official U.S. Government Site for Medicare.
medicare-works-with-other-insurance.html. Accessed December 2, 2016.
17. Your Medicare Coverage. The Official U.S. Government Site for Medicare. Accessed December 2,
18. List of Medicaid Benefits. Keeping America Healthy. Accessed December 4, 2016.
19. Cost Sharing. Keeping America Healthy.
sharing/index.html Accessed December 2, 2016.
20. Medicaid & MIChild Fee-for-Service Handbook. Michigan Department of Health and Human Services. Accessed
December 4, 2016.
21. Healthcare Reform to Make America Great Again. Accessed December 2, 2016.