The cost of health care in the United States is expensive and is escalating. A majority of Americans cannot afford the cost of medicines, physicians’ fees, or hospitalization without some form of health insurance. Health insurance is a contract between an insurance company and an individual or group for the payment of medical care costs. After the individual or group pays a premium to an insurance company, the insurance company pays for part or all of the medical costs depending on the type of insurance and benefits provided. The type of insurance policy purchased greatly influences where you go for health care, who provides the health care, and what medical procedures can be performed. The three basic health insurance plans include a private, fee-for-service plan; a prepaid group plan; and a government-financed public plan.
Private Fee-For-Service Insurance Plan
Until recently, private, fee-for-service insurance was the principal form of health insurance coverage. In this plan an individual pays a monthly premium, usually through an employer, which ensures health care on a fee-far-service basis. On incurring medical costs, the patient files a claim to have a portion of these costs paid by the insurance company. There is usually a deductible, an amount paid by the patient before being eligible for benefits from the insurance company. For example, if your expenses are $1000, you may have to pay $200 before the insurance company will pay the other $800. Usually the lower the deductible, the higher the premiums will be. After the deductible is met the insurance provider pays a percentage of the remaining balance.
Typically there are fixed indemnity benefits, specified amounts that are paid for particular procedures. If your policy pays $500 for a tonsilectomy and the actual cost was $1000, you owe the health care provider $500. There are often exclusions, certain services that are not covered by the policy. Common examples include elective surgery, dental care, vision care, and coverage for preexisting illnesses and injuries. Some insurance plans provide options for adding dental and vision care. Other common options include life insurance, which pays a death benefit, and disability insurance, which pays for income lost because of the inability to work as a result of an illness or injury. The more options added to the insurance plan, the more expensive the insurance will be.
One strategy insurance companies are using to lower insurance premiums and out-of-pocket costs to the consumer is the formation of preferred providers organization (PPO). A PPO is a group of private practitioners who sell their services at reduced rates to insurance companies. When a patient chooses a provider that is in that company’s PPO, the insurance company pays a higher percentage of the fee. When a non-PPO provider is used, a much lower portion of the fee is paid.
A major advantage of a fee-for-service plan is that the patient has options in selecting health-care providers. Several disadvantages are that patients may not routinely receive comprehensive, preventive health care; health-care costs to the patient may be high if unexpected illnesses or injuries occur; and it may place heavy demands on time in keeping track of medical records, invoices, and insurance reimbursement forms.
Prepaid Group Insurance
In prepaid group insurance, health care is provided by a group of physicians organized into a health maintenance organization (HMO). HMOs are managed health-care plans that provide a full range of medical services for a prepaid amount of money. For a fixed monthly fee, usually paid through pay roll deductions by an employer, and often a small deductible, enrollees receive care from physicians, specialists, allied health professionals, and educators who are hired or contractually retained by the HMO. HMOs provide an advantage in that they provide comprehensive care including preventive care at a lower cost than private insurance over a long period of coverage. One drawback is that patients are limited in their choice of providers to those who belong to an HMO.
In a government insurance plan the government at the federal, state, or local level pays for the health-care costs of elgible participants. Two prominent examples of this plan are Medicare and Medicaid. Medicare is financed by social security taxes and is designed to provide health care for individuals 65 years of age and older, the blind, the severely disabled, and those requiring certain treatments such as kidney dialysis. Medicaid is subsidized by federal and state taxes. It provides limited health care, generally for individuals who are eligible for benefits and assistance from two programs: Aid to Families with Dependent Children and Supplementary Security Income.