A short tutorial about "Medical Insurance



Dealing with medical insurance in a pharmacy setting is a very popular task that is being dealt everyday. I will review some very common insurance plans that you will definitely come across with. I want you guys to get a better understanding, get familiar with these types of insurance so when you do come across it you will have an idea on what you are dealing with. Also every state regulates different requirements, regulations and rules, so it is best to double check your state's requirements for these insurance below.


Private Insurance


1. Health Maintenance Organization (HMO): With this medical insurance patients are to visit doctors within your area only, pretty much choose a primary care physician (PCP). Patients would have to pay a copay when visiting your doctor or hospital visit. Premiun coverage would be at a low cost because it provides lesser flexibility in choosing doctors. Here are some insurance companies that offer HMO -- Blue Cross, United Healthcare, Pacificare, Champus Tricare Program, Kaiser, etc.


2. Preferred Provider Organization (PPO): With this medical insurance patients are allowed to choose any doctor within your area or outside of your area. Patients would also have to pay a copay. Premium coverage would be at a high cost because it provides greater flexibility in choosing doctors. This type of insurance is usually convenient for people. Here are some insurance companies that offer PPO -- Blue Shield, Blue Cross, United Healthcare, State Farm, etc.


Government Insurance


1. Medicaid: This governmental insurance is for families who have low income. Each states regulates different requirements, rules and regulations. Patients are not responsibe to pay any medical costs. Some states allow patients to get medicaid with HMO meaning they will get similar benefits that are offered by HMO. Note- The insurance cards may look different for each state but it is similar to the below pictures.



2. Medicare: This governmental insurance are offered only for seniors who are 65+ years of age, the disabled, and dialysis patients. It works much like HMO and PPO. Medicare does not cover prescriptions and patients would have to pay deductable. To help these patients get the best of what they need there are different insurance part plans that are combine with medicare to help them save money. Medicare does not pay for all cost so patients may have to pay a copay, coinsurance, or deductible.




Part A: Hospital insurance

Covers > Inpatient care in hospitals such as their room, doctor fees, tests, food, home health care, etc. 

Who is eligible > Individuals who are 65+ years of age

Monthly premium > It all depends! If they paid Medicare taxes while working then there will not be a premium, this is called "Premium-Free Part A". If the patient is not eligible for Premium-Free Part A then he or she may be able to buy Part A if they are 65+ years of age and is entitled to enroll in Part B and would pay monthly premiums for both.



Part B: Medical insurance

Covers > Doctor visits, preventive screenings, lab tests, x-rays, etc.

Who is eligible > Individuals who are 65+ years of age

Monthly premium > Yes there will be a monthly premium. They can have their monthly premium deducted from their social security each month. If they do not sign up for Part B when first eligible, they may have to pay a late enrollment penalty.



Part C: Medicare Advantage Plan> Plan will provide Plan A and B coverage and at times include Part D that are offered by private companies like HMO and PPO approved by Medicare. Must have Part A and B to be eligible for Part C plan.

Covers > Plan A (Hospital Insurance), Plan B (Medical Insurance) coverage and at times covers Plan D (Prescription Drug Coverage). Also may offer extra coverage such as vision, hearing, dental, health club memberships, etc.

Who is eligible > Individuals who are 65+ years of age 

Monthly Premium > This plan is not free but monthly premium all depends on what the person needs.



Part D: Prescription Drug Coverage > Only availble through private insurance/carriers such as Part C

Covers > Prescription drugs. 

Who is eligible > Individuals who are 65+ years of age

Monthly Premium > There will be a monthly premium.