New Health Insurance Policy

health insurance

health insurance

  Health insurance is insurance that covers a whole or part of the risk of a person incurring medical expenses, which exposes the risk to many individuals.  By assessing the overall risk of health care and health system expenses at the risk pool, an insurer can develop a regular finance structure, such as a monthly premium or payroll tax, to provide funds to pay for health care benefits specified in insurance  Agreement to do.  Profit is operated by a central organization such as a government agency, private business, or not-for-profit organization.

Health Insurance is

  According to the Health Insurance Association of America, health insurance is defined as "coverage that provides for the payment of benefits as a result of illness or injury. This includes losses from accident, medical expenses, disability or accidental death and dissatisfaction.  Insurance is included for "

  A health insurance policy is:

  A contract between an insurance provider (eg an insurance company or a government) and an individual or his / her sponsor (such as an employer or a community organization).  The contract may be renewable (eg annually, monthly) or lifetime in the case of private insurance or mandatory for all citizens in the case of national plans.  The type and amount of health care costs covered by a health insurance provider is specified in writing, in a member contract or "evidence of coverage" booklet for private insurance, or in a national health policy for public insurance.


  In the US, there are two types of health insurance - tax payer-funded and private-funded.  An example of a privately funded insurance plan is an employer-sponsored self-funded ERISA plan.  The company usually advertises that they have one of the larger insurance companies.  However, in the ERISA case, that insurance company "does not engage in the act of insurance", they administer it.  Therefore, ERISA plans are not subject to state laws.  ERISA's plans are governed by federal law under the jurisdiction of the US Department of Labor.  Specific benefit or coverage details are found in the summary plan statement.  An appeal must go through the insurance company, then to the employer's plan.  If still needed, the Fiduciary decision can be brought to USDOL for review for ERISA compliance, and then sued in federal court.

  Individual insured's obligations may have many forms: [citation needed]


  Premium: Policy-holders or their sponsors pay for a health plan to purchase health coverage.  According to healthcare law, a premium is calculated using 5 specific factors in relation to the insured.  These factors are age, location, tobacco use, personal versus 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 individuals who purchase private insurance in the insurance market.

  Deductible: The amount that an insurer must pay out of pocket before the insurer pays its share.  For example, policy holders may have to pay a $ 500 deductible per year before any of their health care is covered by the insurer.  Many may complete doctor visits or prescriptions before the insured reaches the deductible and begins paying for care by the insurance company.  In addition, most policies do not apply co-payments for doctor visits or prescriptions against your deductible.

  Co-payment: The amount that an insured must pay out of pocket before being paid by a health insurer for a particular trip or service.  For example, an insured may pay $ 45 for a doctor's visit, or to obtain a prescription.  Co-payment must be paid each time a particular service is received.

  Coining: Instead of, or in addition to, paying a fixed amount, co-insurance is a percentage of the total cost that the insured can also pay.  For example, a member may have to pay 20% of the cost of surgery over and above one payment, while the insurance company pays the other 80%.  If there is an upper limit on the coins, then the policy holder may have a very small, or very large deal, depending on the actual costs of services received.

  Exclusion: Not all services are covered.  Used and billed items such as throwbacks, taxes etc. are excluded from the admissible claim.  Insurers are usually expected to pay the full cost of non-covered services out of their own pocket.

  Coverage Limits: Some health insurance policies only pay for health care up to a certain dollar amount.  The insured can be expected to pay a fee in excess of the maximum payment of a health plan for a specific service.  In addition, some insurance company plans have an annual or lifetime coverage maxima.  In these cases, the health plan will stop payment when the maximum benefit is reached, and the policy holder will have to pay all remaining costs.


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


  Capitation: The amount paid by an insurance company 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 in the list of providers excluded by the insurer.  The insurer will offer a discounted coin or co-payment or additional benefits to the plan member to see an in-network provider.  Typically, providers in the network are providers that have a contract with the insurer to accept rates that are "normal and customary" beyond what the insurer pays to network providers.

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


  Prior Authorization: A certificate or authority that an insurer provides before having medical service.  Obtaining an authorization means that the insurer is obliged to pay for the service, assuming it is authorized.  Many small, regular services do not require authorization.  


  Formulary: List of medicines that the insurance plan agrees to cover.

  Explanation of Benefits: A document that can be sent by an insurer to a patient explaining what was covered for the medical service, and how the payment amount and the patient's responsibility amount were determined.  In case of emergency room billing, patients are informed within 30 days.  post service.  Until the receipt of this letter, patients are not informed of the cost of emergency room services due to patient status and other logistics.


  Prescription drug plans are a form of insurance offered through some health insurance plans.  The us  In, the patient usually pays a copyright and prescription drug insurance portion or balance for the drugs included in the plan's formulary.  Such schemes are regularly part of national health insurance programs.  For example, in the province of Quebec, Canada, prescription drug insurance is required as part of a public health insurance plan, but can be purchased and administered through private or group plans or a public plan.

  Some, if not most, health care providers in the United States will agree to bill the insurance company. If patients are ready to sign an agreement, they will be responsible for the amount that the insurance company does not pay.  .  The insurance company pays from network providers according to "reasonable and customary" charges, which may be lower than the provider's normal fees.  The provider may also have a separate contract with the insurer to accept what the discounted rate for the provider's standard charges or the amount for capitation is.  This typically costs the patient less to use an in-network provider.

  Comparison

  Per capita health expenditure (in PPP-adjusted US $) among many OECD member states.  Data Source: OECD's iLibrary

  The Commonwealth Fund, in its annual survey, "Mirror, Mirror on the Wall", compares the performance of health care systems in Australia, New Zealand, the United Kingdom, Germany, Canada and the US, although a 2007 study found that,  The US system is the most expensive, consistently underperforming other countries.  The difference between the US and other countries in the study is that the US is the only country without universal health insurance coverage.

  Life expectancy of the total population at birth from 2000 to 2011 among several OECD member countries.  Data Source: OECD's iLibrary

  The Commonwealth Fund completed its thirteenth annual Health Policy Survey in 2010.  A study of the survey found "significant differences in access, cost burden, and problems with health insurance that are associated with insurance design."  In the countries included in the survey, the results indicated that people in the United States had more out-of-pocket expenses, more disputes with insurance companies than other countries, and more insurance payments were denied;  Paperwork was also high, although Germany had higher levels of paperwork.

  Australia

  The Australian public health system is called Medicare, which provides free universal access to hospital treatment and subsidies for out-of-hospital medical treatment.  It is funded by a 2% tax levy on all taxpayers, an additional 1% tax on high-income earners, as well as general revenue.

  The private health system is funded by many private health insurance organizations.  The largest of these is Medibank Private Limited, a state-owned entity until 2014, when it was privatized and listed on the Australian Stock Exchange.

  The Australian Health Fund may be 'for-profit', including Bupa and Nib;  'Mutual' including Australian unity;  Or 'non-profit' including GMHBA, HCF and HBF Health Fund (HBF).  Some, such as police health, membership is limited to particular groups, but most have open membership.  Subscriptions to most health funds are also now available through comparison websites such as Moneytime, Compare Market, iSelect Ltd., Choosi, ComparingExpert and YouCompare.  These comparative sites operate on a commission basis by agreement with their participating health funds.  The Private Health Insurance Ombudsman also operates a free website that allows consumers to search and compare products from private health insurance companies, including information on price and level of cover.

  Most aspects of private health insurance in Australia are regulated by the Private Health Insurance Act 2007.  Complaints and reporting of the private health industry are done by the Private Health Insurance Ombudsman, an independent government agency.  The Ombudsman publishes an annual report which outlines the number and nature of complaints per health fund as compared to its market share.

  The private health system in Australia operates on the basis of a "community rating", under which premiums do not just vary (but below the lifetime) due to an individual's past medical history, current state of health, or (generally speaking) age.  See health cover).  To balance this period is a waiting period specifically for pre-existing conditions (commonly referred to within the industry as PEA, which is a "pre-existing disease").  The fund is entitled to impose a waiting period of up to 12 months on the benefits of any medical condition, the signs and symptoms of which were present during the six months the person was previously insured.  They are also entitled to impose a 12-month waiting period for benefits for maternity-related treatment and a 2-month waiting period for all other benefits when a person takes private insurance for the first time.  In individual cases the fund has discretion to reduce or remove such waiting period.  money.

 Canada


  According to the Canadian Constitution, health care is primarily the responsibility of a provincial government in Canada (the main exception being the responsibility of the federal government provided by those joining the treaties, the Royal Canadian Mounted Police, the Armed Forces and Members of Parliament  Is the responsibility of the federal government for services).  As a result, each province operates its own health insurance program.  The federal government affects health insurance based on its financial powers - it transfers cash and tax points to the provinces to help cover the costs of universal health insurance programs.  Under the Canada Health Act, the federal government enforces the imperative and the requirement that all people be defined as "medically necessary services" defined as care delivered primarily by physicians or hospitals  , And nursing component of long-term residential attention.  If provinces allow doctors or institutions to charge patients for medically necessary services, the federal government reduces their payments to the provinces by the amount of the restricted fee.  Collectively, the public provincial health insurance system in Canada is often referred to as Medicare.  This public insurance is tax-funded out of general government revenue, although British Columbia and Ontario impose a mandatory premium for individuals and families with flat rates - to generate additional revenue - in short, a facelift.  Private health insurance is permitted, but only for services in six provincial governments that do not cover public health plans (eg, semi-private or private rooms in hospitals and prescription drugs plans).  The four provinces allow insurance for services mandated by the Canada Health Act, but in practice there is no market for it.  All Canadians are free to use private insurance for alternative medical services such as laser vision correction surgery, cosmetic surgery and other non-basic medical procedures.  Some 65% of Canadians have some form of supplementary private health insurance;  Many of them get it through their employers.  Private sector services have not been paid by the government for about 30 percent of total health care spending.

  In 2005, the Supreme Court of Canada ruled in Chaulai v. Quebec that the province's prohibition on private insurance for health care, already insured by the Provincial Plan, violated the Quebec Charter of Rights and Freedom, and in particular  Section relating to the right to life and safety, if treatment was unacceptably long waited for, as in this case R.  As was imposed.  The ruling has not changed the overall pattern of health insurance across Canada, but has diverted efforts to deal with core issues of supply and demand and the impact of waiting times.

  France

  The national system of health insurance was introduced in 1945, just after the end of World War II.  It was an agreement between the Gaulist and Communist representatives in the French Parliament.  Conservative Gaulists were opposed to a state-run health system, while the Communists were advocates for the complete nationalization of health care with the British Beveridge model.

  The resulting program is profession-based: all working people are required to contribute a portion of their income to a not-for-profit health insurance fund, which increases the risk of illness, and which reimburses medical expenses at varying rates  .  Children and spouses of the insured are eligible for benefits.  Each fund is free to manage its own budget, and is used to reimburse medical expenses, as it sees fit, although after a number of reforms in recent years, most of the funds are available for reimbursement and benefits.  Provides the same level.

  The government has two responsibilities in this system.

  The first government responsibility is to fix the rate at which medical expenditures should be negotiated, and this happens in two ways: the Ministry of Health negotiates drug prices directly with manufacturers, which is the average of observed sales in neighboring countries  Is based on price.  .  A board of doctors and experts decides whether the drug provides a substantial enough medical benefit to be reimbursed (note that most of the medication is reimbursed, including homeopathy).  In parallel, the government sets the reimbursement rate for medical services: this means that a doctor is free to charge the fees he wants for counseling or examination, but the social security system will only reimburse at a pre-determined rate.  These fees are determined annually through negotiations with representative organizations of doctors.

  The second government responsibility is the monitoring of health-insurance funds, to ensure that they are properly managing the amounts received, and to monitor public hospital networks.

  Today, this system is more or less intact.  All citizens and legal foreign residents of France are covered by one of these mandatory programs, funded by labor participation.  However, many major changes have been introduced since 1945.  First, the various health care funds (five are: general, independent, agriculture, students, public servants) are now reimbursed at the same rate.  Secondly, since 2000, the government now provides health care to those who are not covered by a mandatory regime (those who have never worked and those who are not students, which means very rich or very poor).  This regime, unlike worker-financed ones, is financed through general taxation and reimburses at a higher rate than the profession-based system for those who cannot differentiate.  Finally, to combat the increase in health care costs, the government has instituted two schemes, (in 2004 and 2006), in which a referenced to fully reimburse the insured for specialist visits.  Requires a doctor to be declared, and who has established a mandatory co-payment of € 1 for a visit to a doctor, € 0.50 for each box of prescribed medicine,  And a fee of € 16–18 per day for hospital stays and costly procedures.

  One important element of the French insurance system is solidarity: the more a person is ill, the less a person pays.  This means that for people with serious or chronic illnesses, the insurance system reimburses them 100% of expenses, and waives their co-payment fees.

  Finally, for fees that do not cover the compulsory system, there is a large range of private supplemental insurance plans available.  The market for these programs is very competitive, and is often subsidized by employers, meaning that the premiums are usually modest.  85% of French people benefit from supplementary private health insurance.  [24]

  Germany

  Germany has the oldest national social health insurance system in the world, which originated with Otto von Bismarck's disease insurance law of 1883.

  Beginning with 10% of blue-collar workers in 1885, compulsory insurance has expanded;  In 2009, insurance was made mandatory on all citizens, with self-employed or private health insurance above the income limit.  [2 made] [21] As of 2016, 85% of the population is covered by compulsory statutory health insurance (gesitzli kranikeverieserung or gkv), with the remainder being private insurance (private kranikwreiser or pkv). Germany's health care system is 77% government funded.  And 23%.  Privately funded 2004.While public health insurance contributions are based on a person's income, private health insurance contributions are based on the person's age and health status.

  Reimbursement is on a fee-on-service basis, but the number of physicians allowed to accept statutory health insurance at a given location is regulated by the government and professional societies.

  Co-payment was introduced in the 1980s in an effort to curb excess usage.  The average length of hospital stay in Germany has been reduced from 14 days to 9 days in recent years, still being longer than the average (5 to 6 days) in the United States.  The difference is the main consideration for hospital reimbursement.  Number of hospital days as opposed to procedures or diagnosis.  The cost of medicine has increased significantly, increasing nearly 60% from 1991 to 2005.  Despite efforts to curb costs, overall health care expenditures rose to 10.7% of GDP in 2005, compared to other Western European countries, but significantly lower than those spent in the US.  (About 16% of GDP).

  Germans are offered three types of Social Security insurance to deal with an individual's physical condition and which are co-financed by employer and employee: health insurance, accident insurance, and long-term care insurance.  In 1994, long-term care insurance (Gesitzliffe Pflecevericherung) emerged and is mandatory.  [29] Accident insurance (gesetzliche Unfallversicherung) is covered by the employer and basically covers all risks to work and to the workplace.  [Citation needed]

  India

  In India, the provision of health care services varies state-wise.  Public health services predominate in most states, but due to insufficient resources and management, large populations oppose private health services.

  To improve awareness and better healthcare facilities, the Insurance Regulatory and Development Authority of India and the General Corporation of India conduct health care campaigns for the entire population.  In 2018, for privileged citizens, Prime Minister Narendra Modi announced the introduction of a new health insurance called Modicare and the government claims that the new system will try to reach more than 500 million people.

  In India, health insurance is mainly given in two types:

  The indemnity plan basically covers hospital expenses and consists of subtypes such as personal insurance, family floater insurance, senior citizen insurance, maternity insurance, group medical insurance.

  Fixed benefit plan pays a fixed amount for pre-decided diseases like critical illness, cancer, heart disease etc. There are also sub-types like preventive insurance, critical illness, personal accident.

  Depending on the type of insurance and the company providing health insurance, the coverage includes pre and post hospitalization fees, ambulance fees, day care fees, health screenings, etc.

  It is important to know about the exclusions that do not come under insurance plans:

  Treatment related to dental disease or surgery

  All types of STDs and AIDS

  Non allopathic treatment

  Some of the companies provide insurance against such diseases or conditions, but this depends on the type and sum insured.

  Some important aspects to be considered before choosing health insurance in India are the claim settlement ratio, insurance limit and caps, coverage and network hospital.

  Japan

  There are two major types of insurance programs available in Japan - employee health insurance.  National Health Insurance is designed for those who are not eligible to become members of any employment-based health insurance program.  Although private health insurance is also available, all Japanese citizens, permanent residents and non-Japanese living for a year or longer are required to be enrolled in National Health Insurance or Employee Health Insurance.

  Netherlands

  In 2006, a new system of health insurance came into force in the Netherlands.  This new system avoids two disadvantages of adverse selection and moral hazard associated with traditional forms of health insurance using a combination of regulation and an insurance equation pool.  Ethical risk is avoided by stating that insurance companies provide at least one policy that meets the minimum standard level of standard to a government, and all adult residents must by law extend this coverage to the insurance company of their choice  Are obliged to buy.  All insurance companies receive funding from the same pool to help cover the cost of this government-mandated coverage.  The pool is run by a regulator, which collects salary-based contributions from employers, who make up about 50% of all health care funds, and gets funding from the government to cover those who care for health care.  Can not afford, which makes an additional 5%.

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