Who Insures You?

Healthcare Finance Presentation by

Erin, Jeff, Maricor, Hana

Types of Insurance
Employer-Provided Health Insurance the primary source of health insurance for nonelderly
Americans. Coverage depends on the company as well as state laws (KFF.org).
Private Insurance policyholders pay a premium that varies by insurance provider and amount
of coverage. In 2017, premiums are expected to be between $229 and $904 (KFF.org).
Patient Protected Affordable Care Act (PPACA) also known as Obamacare is an act that
extends Medicaid coverage to low-income individuals and families. It also grants coverage to
individuals under the age of 26. Under PPACA, insurers are prohibited from denying coverage
to individuals due to a preexisting condition (KFF.org).
Medicare offers health insurance to people 65 years or older, or people under 65 who
Have been receiving Social Security Disability Insurance
Have been diagnosed with amyotrophic lateral sclerosis (ALS)
Have been diagnosed with end stage renal disease (ESRD)
Medicare is premium-free if the policyholder paid Medicare taxes while working. (Medicare.gov)

Types of Insurance cont.

Medicaid is a subsidized insurance plan for low-income individuals and families. Each state has the option to add

their own benefits, such as prescription drug coverage and PT/OT, but federal law mandates that
inpatient/outpatient care, lab and imaging services, and home health care be provided (Medicaid.gov). Hawaiis
income limit to receive Medicaid benefits is $18,257/year for a non-disabled adult and $31,008 for a family of 3
(KFF.org)
Workers Compensation is administered on a state-by-state basis (dol.gov). In Hawaii, medical bills incurred by a

work-related accident are sent to the companys insurance provider for payment. The employer should have WC
insurance to reimburse for wages lost due to injury (labor.hawaii.gov).
TRICARE -Provides benefits for Active Duty personnel, Retirees, Reservists, and Guard members called to Active

Duty and certain family member. TRICARE offers a comprehensive rehabilitation benefit that includes
occupational therapy (OT), physical therapy (PT), speech therapy and behavioral health services when ordered
by a physician as part of a comprehensive individual rehabilitation treatment plan. Individual therapists
commonly incorporate CRT techniques into covered services which are reimbursed under each separate therapy.

Case #1: Joe Smith

Joe Smith is a 68 year old male, retired, with a yearly income of

$12,000. He has a history of type 2 diabetes mellitus.

Case #1: Joe Smith

Joe Smith has type 2 diabetes mellitus and requires a short acting insulin (Novolin)
before meals, a long-acting insulin (Levemir) in the morning, and a daily oral
antidiabetic (metformin). The cost of his medications and supplies are listed below:

Who Covers Joe Smith?

Medicare and Medicaid

Over 65
Yearly income $12,000
Eligible for SSDI

Case Study #2: Katie Hughes

Katie Hughes is a 61 year old female, unemployed, with an
annual income of $15,000. She recently lost her job and was just
diagnosed with a brain tumor.

Who covers Katie Hughes?

Medicaid
Income is less than 18,257 per year.
PPACA allows access to care.

Case #3: Maria Lopez

Maria Lopez is a 68 year old retired female with an annual
household income of $300,000. She was just diagnosed with a
brain tumor.

Who covers Maria Lopez?

Medicare
Older than 65 years old

Private Insurance

Who covers Maria Lopez?

Brain Tumor Healthcare Costs

For patients covered by health insurance, the typical cost of brain tumor treatment will include doctor copays, drug copays and

coinsurance of 10-50% or more -- most likely reaching the yearly out-of-pocket maximum. Brain tumor treatment typically is
covered by health insurance.
For patients not covered by health insurance, the typical cost of brain tumor treatment can range from less than $50,000 for a

small benign tumor in an accessible location that can be treated with surgery alone up to $700,000 or more for a malignant tumor
that must be treated with some combination of surgery, radiation and chemotherapy. For example, the cost of brain surgery is
typically $50,000-$150,000 or more. Dartmouth-Hitchcock Medical Center[1] in New Hampshire charges about $72,500 for brain
surgery, including hospital charge and doctor fees, after a 30% uninsured discount. Saint Elizabeth Medical Center[2] in Nebraska
charges about $33,600-$78,700,not including doctor fees. And Baptist Memorial Healthcare in Memphis charges almost
$50,000without major complications to almost more than $110,000 with major complications, not including the doctor fees, which
can add up to $30,000 or more to the final bill.
Stereotactic radiosurgery, a type of radiation therapy commonly used on brain tumors, typically costs $12,000-$55,000; however,

additional treatments sometimes are required for recurring or new tumors, so total costs can easily reach $100,000 or more. The
cost of chemotherapy varies widely based on the drug, how it is administered and how many treatments are required -- and costs
commonly reach tens of thousands of dollars.
The Brain Tumor Foundation estimates[3] the cost of treating a glioblastoma at more than $450,000and says costs of treating a

Case Study #4: Bud Sanders

Bud Sanders is a 55 year old male with type 2 diabetes mellitus.
He is a retired military veteran with an annual income of
$25,000.

Who covers Bud Sanders?

PPACA
Income too high to qualify for Medicaid
Retired
Veteran

Tricare
Retired veteran (assuming 20 or more years of service)

Case Study #5: Brandon Ames

Brandon Ames is a 25 year old seasonal snowboard instructor
who broke his leg while at work. He earns $12,000 per year and
he currently has no health insurance.

Who Covers Brandon Ames?

PPACA
Medicaid
Workers Compensation

Case#6 Karen Davis

Karen Davis is 25 year old active duty air force who has a
traumatic brain injury. Family annual income of $36,000/year

Who covers Karen Davis?

TRICARE
PPACA