Health Insurance Explained

read also:  Health Insurance Coverage by State

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  1. The US market-based health care system

  2. The term Health Insurance

  3. Health insurance policy explained

  4. Premium

  5. Copayment

  6. Coinsurance

  7. Insurance coverage limits

  8. Out of pocket maximums

  9. Capitation

  10. In Network Provider

  11. Health plan versus health insurance

  12. Comprehensive versus. scheduled

  13. Problems inherent to insurance

  14. Adverse selection

  15. Moral hazard

  16. Other factors affecting insurance costs

  17. Student Health Insurance

  18. Student Health Insurance options

  19. Medicare

  20. Medicare Eligibility

  21. Prescription drug plans

  22. Medicare Prescription Drug Plan Finder




The US market-based health care system relies to a great extent on private and not-for-profit health insurance, which is the main source of coverage for most Americans. According to the U.S.A. Census Bureau, around 84% of Americans carry health insurance; around 60% receive it via an employer, whilst around 9% buy it straight off. Diverse government agencies offer coverage to around 27% of Americans (there might be some overlap in these figures).

Public programs provide the main source of coverage for many seniors and for low income families that meet certain eligibility prerequisites. The more common public programs are Medicare, a Fed social insurance program for seniors and some incapacitated individuals, Medicaid, funded collectively by the Fed government and states but administrated at the state level, which covers some very low income minors and their households, and SCHIP, likewise a federal state partnership which assists those children and families who don't qualify for Medicaid yet cannot afford private insurance coverage.

Additional public programs comprise armed forces health benefits offered by TRICARE and the Veterans Health Administration and benefits allowed for via the Indian Health Service. Certain states have further programs for low income individuals.

The term Health Insurance  [Top]

The term Health Insurance is normally used to describe a type of insurance that covers medical expenditures. It's occasionally utilized more broadly to comprise insurance covering disablement or long-term nursing or custodial care needs. It could be offered by a government sponsored social insurance program, or through private insurance firms.

It can be bought on a group basis (for example by a company to insure its employees) or bought by private individuals. For each case, the covered groups or individuals pay insurance premiums or taxes to help safeguard themselves from high or unforeseen health care expenditures. Alike benefits paying for medical expenditures can as well be provided via social welfare programs established by the state.

By approximating the general risk of health care expenditures, a routine finance structure (such as a every month premium or yearly tax) can be formulated, assuring that funds are disposable to pay for the health care benefits delineated within the insurance policy agreement.

The benefit is administrated by a centered organization, typically either a government agency or a private or not for profit entity running a health program

Health insurance policy explained  [Top]

A health insurance policy is a contract between an insurance company and an individual. The contract can be renewable each year or each month. The kind and add up of health care expenditures which are be covered by the health plan are stipulated beforehand, in the member contract or Evidence of Coverage booklet. Each policy-holder's payment obligations can take various forms:


 The sum of money the policy holder pays to the health program every month to buy health insurance coverage.

Deductible: The sum of money that the policy-holder must pay up before the health program pays for its share. For instance, a policy holder might have to pay a $500 deductible annually prior to any of their health care is covered by the health plan. It can take several doctor's visits or prescription refills before the policy holder arrives at the deductible and the health plan starts to pay for care.

Copayment  [Top]

The sum of money that the insurance policy holder must pay up before the health plan compensates for a specific visit or service. E.g., a policy holder could pay up a $45 copayment for a doctor's visit, or to get a prescription. A copayment has to be paid every time a specific service is received.

Coinsurance  [Top]

Rather than paying a fixed amount of money in advance (a copayment), the insurance policy holder has to pay a portion of the complete cost. E.g., the insurance holder could have to pay 25% of the cost of a surgical procedure, whilst the health plan covers the other 75%. Since there is no upper limit on coinsurance, the insurance policy holder could end up owing little, or a big amount, dependant on the actual expenditures of the services they receive.
Exceptions: Not all services are covered. The insurance policy holder is usually required to bear the entire price of uncovered services themselves.

Insurance coverage limits  [Top]

A few health insurance plans solely pay for health care up to a definite amount of money. The insurance policy holder may have to pay up any charges in excess of the health plan's upper limit payment for a particular service. Additionally, a few insurance plans have yearbook or lifetime insurance coverage maximums. Within these cases, the health program will cease payment once they arrive at the benefit upper limit, and the insurance policy holder has to pay up all remaining expenditures.

Out of pocket maximums  [Top]

Alike to insurance coverage limits, except that in this case, the member's payment obligation ceases once they arrive at the out of pocket maximum, and the insurance health plan pays for all additional covered up costs. Out of-pocket maximums can be restricted to a particular benefit category (for instance prescription drugs) or could apply to all coverage provided on a particular benefit year.

Capitation  [Top]

 A total amount paid by an insurance firm to a health professional, for which the insurance firm agrees to care for all members of the insurance firm.

In Network Provider  [Top]

 A health care provider on a list of providers preselected by the insurance firm. The insurance firm will offer discounted coinsurance or copayments, or further benefits, to an insurance plan member to see an in network provider. Typically, providers in network will be providers who have a contract with the insurance firm to accept rates further discounted from the 'usual and customary' rates the insurance company pays to out of network providers.

Prescription drug plans [Top]

Prescription drug plans are a sort of insurance plan offered via some employer benefit plans in the U.S.A., where the patient pays up a copayment and the prescription drug insurance part or all of the balance for drugs covered up in the formulary of the plan.

A few, if not most, insurance health care in the U.S.A. will agree to charge the insurance firm if patients are consenting to sign an agreement that they will be accountable for the amount of money that the insurance firm does not pay. The insurance firm pays out of network providers concordant to "reasonable and customary" charges that may be inferior than the provider's habitual fee. The provider could also carry a separated contract with the insurance firm to accept what amounts to a discounted rate or capitation to the provider's regular charges. It normally costs the patient less to use an in network provider.

Medicare Prescription Drug Plan Finder from the  official website (outside link)

Health plan versus health insurance  [Top]

Historically, HMOs tended to use the terminus "health plan", while commercialized insurance carriers used the term "health insurance". A health plan can also refer to a subscription based medical care agreement offered up through HMOs, chosen provider organizations or point of service plans. These plans are akin to pre paid dental, pre paid legal, and pre paid vision plans.

 Pre paid health plans generally pay for a fixated number of services (for example, $300 in preventive care, a definite number of days of hospice care or care in a competent nursing facility, a definite amount of home health visits, a definite number of spinal manipulation expenditures, etc.) The services offered are normally at the discretion of a utilization review nurse who is oftentimes contracted via the managed care entity offering the subscription health plan. This determination can be made either before or subsequent hospital admission (concurrent utilization review).

Comprehensive versus scheduled  [Top]

Comprehensive health insurance pays for a part of the cost of hospital and doctor charges after a deductible (generally applies to hospital expenditures) or a co pay (generally applies to doctor charges, but could apply to some hospital services) is met by the insured. These plans are typically pricey due to the high potentiality benefit payout ($1,000,000 to 5,000,000 is most common), and due of the vast range of covered benefits.

Scheduled health insurance plans are not designed to substitute a conventional comprehensive health insurance plans and are more of a basic policy allowing for access to day-after-day health care such as visiting the doctor or obtaining a prescription drug. In late years, these plans have taken the name mini-med plans or association plans. These plans might offer hospitalization and surgical benefits, but these benefits will be moderate.

Scheduled plans are not intended to be efficient for catastrophic events. These plans cost a good deal less than comprehensive health insurance. They usually pay limited benefits amounts directly to the service provider, and payments are based on the plan's 'schedule of benefits'. Annual benefits maximums for a common scheduled health insurance plan could range from $1,000 to $25,000.

Problems inherent to insurance  [Top]

Insurance systems typically have to deal with two inherent challenges: adverse selection, which affects any voluntary system, and ex post moral hazard, that affects eventual insurance system where a third party accepts major responsibleness for payment, whether that is an employer or the government. A few national systems with compulsory insurance employ systems such as risk equalization and community rating to overcome these inherent problems.

Adverse selection  [Top]

Insurance firms use the term "adverse selection" to delineate the tendency for only those who will benefit out of insurance to buy it. Specifically when talking of health insurance, unhealthy people are more probable to go for health insurance as they expect large medical bills. On the other side, individuals who consider themselves to be fairly healthy could decide that medical insurance is an unneeded expense; if they visit the doctor once a year and it costs $250, that's a great deal better than making each month insurance payments of for example $40.

The fundamental concept of insurance is that it balances expenditures across a large, random sample of people (risk pool). For example, an insurance firm has a pool of 1000 randomly selected subscribers, each paying $100 monthly. One person gets very ill while the others remain healthy, leaving the insurance firm to utilize the premiums paid for by the healthy people to pay for the treatment expenditures of the diseased person. All the same, when the pool is self selecting rather than random, such is the case with consumers searching to purchase health insurance directly, adverse selection is a greater concern. A disproportional share of health care expending is credited to people with high health care costs. In the United States the 1% of the population with the highest spending accounted for 27% of aggregate health care spending in 1996.

Moral hazard  [Top]

Moral hazard takes place when an insurance company and a consumer enter into a contract under symmetric information, but one party takes action, not described in the contract, which alters the value of the insurance. A typical example of moral hazard is third party payment: whenever the parties involved in arriving at a decision are not responsible for bearing costs originating from the decision. A good example is when physicians and insured patients agree to extra tests which may or may not be indispensable.

 Physicians benefit by warding off possible malpractice suits, and patients do good by gaining added to certainty of their medical condition. The cost of these additional tests is borne by the insurance firm, who may have had little input in the matter. Co-payments, deductibles, and less forgiving insurance for services with more elastic demand try to fight moral hazard, as they hold the consumer accountable.

Other factors affecting insurance costs

A recent study by Price Waterhouse Coopers analyzing the drivers of rising health care costs in the U.S.A. Indicated to increased utilization produced by increased consumer demand, new treatments, and more involved diagnostic testing, as the most important driver. People are living longer. The population is ageing, and a bigger group of older citizens necessitates more intense medical care than a young fitter population.

Advancements in medicine and medical technology could also step-up the price of medical treatment. Lifestyle associated factors can increment utilization and so insurance costs, for instance increments in obesity induced by not enough physical exercise and unhealthful food choices; unrestrained alcoholic beverage use, smoking, and drug abuse. Additional factors noted by the Price Waterhouse Coopers report included the movement to broader access plans, higher priced technologies, and cost shifting from Medicaid and the uninsured to private payers.

Student Health Insurance  [Top]

Student medical health insurance is good for students as it provides them with complete coverage.

Student and college health insurance plans have become very popular amongst students and parents. The chief reason is that nearly all colleges and universities want students to have health insurance coverage making it an essential requisite of the enrollment process.

Coverage is obligatory for part time and full-time students. Numerous international health insurance carriers provide student and college insurance to students. Not only does it makes sure that students stay healthy during studies but helps them obtain higher marks too.

Getting student health insurance is essential for students as they do not get the required treatment at the localized college medical clinic very frequently. This is a sizeable disadvantage as students may have grave health problems due to the lack of appropriate health care facilities. That's why it's of great importance to join the right student health insurance program so as to get proper health care.

Student Health Insurance options  [Top]

There are numerous options for students to look at if they want to maintain health insurance after moving out from home and entering university.
With several health insurance plans they may remain on the parents' health insurance plan if the student is between nineteen and twenty-five years old.

If one is over twenty-five and is still attending school, or resolves not to continue studying after the age of eighteen, he will in nearly all cases lose the health insurance coverage from his parents. But with the help of the Consolidated Omnibus Budget Reconciliation (AKA COBRA) he may stay with the coverage from his parents.

A short term health insurance policy ought to be considered when one is not in college and can not utilize COBRA. This insurance coverage is a great impermanent answer to the problem until he/she is employed and able to use the health care plan from their employer.

Medicare  [Top]

Medicare is a social insurance program administrated by the US Government, providing health insurance coverage to individuals of at least 65 years of age, or who meet some other specific criteria.
Medicare functions as a single payer health care system. It came into place on July 30, 1965, signed into law by President Lyndon B. Johnson as amendments to Social Security legislation.

Medicare Eligibility  [Top]

As a whole, individuals are entitled tor Medicare if they are a U.S.A. citizen or have been a permanent legal resident for five uninterrupted years, and they are sixty-five years (or older), or if they are under sixty-five they are disabled and have been receiving either Social Security or the Railroad Retirement Board disablement benefits for at least twenty-four months, or they get continuing dialysis for end stage renal disease or need a kidney transplant, or they are qualified for Social Security Disability Insurance and have Amyotrophic Lateral Sclerosis (ALS-Lou Gehrig's disease).

Numerous beneficiaries are dual eligible. This means that they qualify for both Medicare and Medicaid. In certain states for those earning under a certain income, Medicaid will pay the beneficiaries' Part B premium for them (however most beneficiaries have worked long enough and have no Part A premium), and also pay for any drugs which are not covered by Part D.

In 2007, Medicare provided health care insurance coverage for forty-three million American citizens. Enrolment is anticipated to reach seventy-seven million by 2031, once the baby boom generation is fully enrolled.

If you wish to see if you qualify for Medicare, THIS  (outside link) is the direct link to the Medicare Eligibility Tool from the the official Government (outside link) website.



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