Health Insurance

Health insurance covers the whole or part of risk of person incurring medical expenses. As other types of insurance, risk is shared among many individuals. By estimating the overall risk of health risk and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization, such as a government agency, private business, or not-for-profit entity.

A health insurance policy, contract between an insurance provider (e.g. an insurance company or a government) and an individual or his/her sponsor (that is an employer or a community organization). The contract can be renewable (annually, monthly) or lifelong in the case of private insurance. It can also be mandatory for all citizens in the case of national plans. The type and amount of health care costs that will be covered by the health insurance provider are specified in writing, in a member contract or "Evidence of Coverage" booklet for private insurance, or in a national health policy for public insurance.

Types of Health Insurance

There are two types of health insurance – tax payer-funded and private-funded. A private-funded insurance plan example includes an employer-sponsored self-funded ERISA (Employee Retirement Income Security Act of 1974) plan. Typically, these companies promote themselves as having ties to major insurance providers. However, in the context of an ERISA plan, these insurance companies do not actively participate in insurance practices; instead, they handle administrative tasks. Consequently, ERISA plans are exempt from state regulations and fall under federal jurisdiction, overseen by the US Department of Labor (USDOL). Specific details about benefits or coverage can be found in the Summary Plan Description (SPD). Should there be a need for an appeal, the process typically involves initiating it through the insurance company and then reaching out to the Employer's Plan Fiduciary. If a resolution is still not achieved, the decision can be escalated to the USDOL for review to ensure compliance with ERISA regulations, and, if necessary, legal action can be taken by filing a lawsuit in federal court. Health insurance can be combined with publicly funded health care and medical savings accounts.

The individual insured person's obligations may take several forms

Premium: The amount the policy-holder or their sponsor (e.g. an employer) pays to the health plan to purchase health coverage. (US specific) According to the healthcare law, a premium is calculated using 5 specific factors regarding the insured person. These factors are age, location, tobacco use, individual vs. family enrollment, and which plan category the insured chooses. Under the Affordable Care Act, the government pays a tax credit to cover part of the premium for persons who purchase private insurance through the Insurance Marketplace.

Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. For example, policy-holders might have to pay a $7500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor's visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care. Furthermore, most policies do not apply co-pays for doctor's visits or prescriptions against the insured's deductible.

Co-payment: The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service. For example, an insured person might pay a $45 co-payment for a doctor's visit, or to obtain a prescription. A co-payment must be paid each time a particular service is obtained.

Coinsurance: Instead of, or in addition to, paying a fixed amount up front (a co-payment), the co-insurance is a percentage of the total cost that an insured person may also pay. For example, the member might have to pay 20% of the cost of a surgery over and above a co-payment, while the insurance company pays the other 80%. If there is an upper limit on coinsurance, the policy-holder could end up owing very little, or a great deal, depending on the actual costs of the services they obtain.

Exclusions: Not all services are covered. Billed items like disposables, taxes, etc.[clarification needed] are excluded from admissible claim. The insured are generally expected to pay the full cost of non-covered services out of their own funds.

Coverage limits: Some health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some insurance company schemes have annual or lifetime coverage maxima. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining costs.

Out-of-pocket maximum: Similar to coverage limits, except that in this case, the insured person's payment obligation ends when they reach the out-of-pocket maximum, and health insurance pays all further covered costs. Out-of-pocket maximum can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.

Capitation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer.

In-Network Provider: (U.S. term) A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or co-payments, or additional benefits, to a plan member to see an in-network provider. Generally, providers in network are providers who have a contract with the insurer to accept rates further discounted from the "usual and customary" charges the insurer pays to out-of-network providers.

Out-of-Network Provider: A health care provider that has not contracted with the plan. If using an out-of-network provider, the patient may have to pay full cost of the benefits and services received from that provider. Even for emergency services, out-of-network providers may bill patients for some additional costs associated.

Prior Authorization: A certification or authorization that an insurer provides prior to medical service occurring. Obtaining an authorization means that the insurer is obligated to pay for the service, assuming it matches what was authorized. Many smaller, routine services do not require authorization.

International Insurance Policies

1. Individual & Family Insurance
2. Maternity Insurance
3. Pre-Existing Conditions
4. Short Term Insurance
5. Senior Citizen Insurance
6. Emergency Evacuation Insurance