Overview and Learning Objectives

Health insurance offers financial protection from sickness and injury, but the policies and procedures outlined in a health insurance policy can be very involved. This chapter, as well as the following chapters, will cover the basics of those policies including plans, providers, provisions, underwriting standards and other characteristics of health insurance.

There are various types of contracts that are considered health insurance or health care types of coverages and it is important to identify the characteristics of each.

• Do they reimburse the insured for actual expenses?
• Do they simply pay a stated (flat) dollar amount per day?
• Are the services provided by the doctors or hospitals (health care providers) paid in advance by the insurance company or do they receive a "fee" for their services negotiated in advance?

In the past, health insurance contracts excluded from coverage pre-existing conditions and imposed lifetime or annual benefit limits. If a medical condition existed before the effective date of the contract, this could be excluded from coverage for a certain period. However, the Affordable Health Care Act (ACA) now prevents insurers from excluding pre-existing conditions and does not allow a policy to have annual or lifetime maximums. But not all policies fall under the ACA. So, which policies fall under the ACA?

Most employer sponsored plans, as well as HMOs, PPOs, POS, and health plans bought through the Health Insurance Marketplace fall under the requirements of the ACA. Others do not.

Some products that help pay for medical services don't qualify. Examples include:

• Coverage only for vision care or dental care
• Coverage only for a specific disease or condition
• Workers' compensation

The arena for the health license offers tremendous opportunities for financial growth as well as the satisfaction of helping others choose the right product for their specific need.