US Healthcare - Trends 2013

In Previous year 2012 lot many things happened in U.S. health insurance industry. The Affordable Care Act (ACA) continued to charge ahead despite widespread controversies including a ruling by the Supreme Court and became charged with a fresh line of life when President Obama won his second term in office.

Last year we witnessed the rise of private health exchanges, payer-provider mergers, Accountable Care Organizations (ACOs), 2013 is now poised to see some important developments and new trends in the U.S. healthcare sector. Some of the landmark changes that are sure to gain dominance in 2013 include:


1. The Year of the State Health Insurance Exchanges – Although the ACA has declared January 1, 2014 as the official Go-Live date for state health insurance exchanges, both state and federal exchanges are expected to open for public enrollment in the last quarter of 2013. As current controversies and conflicts around health exchanges spill into 2013, exchanges are expected to remain the hot topic of debate throughout the year.

2. Increased Measures to reduce Healthcare Costs – Lot many Federal programs such as “Pay-for-Performance” and Medicare’s “Hospital Re admissions Reduction Program” sought to reduce healthcare costs in 2012 through improved efficiency and quality in administered care. With healthcare costs reigning at the top of the industry’s primary challenges, 2013 will likely yield stringent measures aimed at restraining growth in healthcare costs.

3. Growth in Private Health Insurance Exchanges – Private health insurance exchanges is gaining popularity in group markets, providing visible advantages such as increased flexibility in health coverage and higher predictability in costs as compared to ACA-mandated public exchanges that are still shrouded in uncertainties. Increased employer demand for Defined-Contribution Plans led to the launch of several private health insurance exchanges in 2012, with the trend expected to continue strong into 2013.

4. Surge in Employer-sponsored Wellness Services – With employers’ healthcare costs sky rocketing at alarming rates, employee wellness programs have been pushed to the forefront of health benefits. As employee engagement gains unprecedented popularity, insurance carriers and wellness providers are adapting their health benefit portfolios to encourage healthy lifestyles among employees.

Despite several nerve-racking events, President Obama’s healthcare law survived last year. As we step forward into 2013, the U.S. healthcare industry is expected to become fraught with increased activity as federal and state exchanges gradually emerge onto the U.S. landscape, private exchanges gain ground in group markets, Medicare and Medicaid receive an overhaul, and consumers get acquainted with the new, digital way of purchasing their health insurance.

The U.S. healthcare industry’s journey through 2013 will be a sight to watch as trends continue to emerge.

US Health Care Law

In US Health Care Law plays very important role . These are the laws passed or you can say approved by federal government to make Medical Healthcare/ Healthcare Insurance market work better for individuals , families, students , retired persons , old peoples . Almost covering each and every human being present in country .

As per new Health Care Law in US it protects consumers against worst insurance practices. After New US Health care law health insurance protections for all Americans moves forward. As per new Healthcare law in US issued they implemented five key consumer protections from the Affordable Care Act and makes the health care insurance market better for individuals, families and small businesses.

As per Secretary Kathleen Sebelius " being sick will no longer keep you ,your family or your employees from being able to get affordable health coverage".

As per these reforms all individuals and employees have the right to purchase health insurance coverage regardless of their health status.  In addition, insurers are prevented from charging discriminatory rates to individuals and small employers based on factors such as health status or gender, and young adults have additional affordable coverage options under catastrophic plans.

This final rule implements five key provisions of the Affordable Care Act that are applicable to non-grandfathered health plans:

Guaranteed Availability
Nearly all health insurance companies offering coverage to individuals and employers will be required to sell health insurance policies to all consumers. No one can be denied health insurance because they have or had an illness.

Fair Health Insurance Premiums
Health insurance companies offering coverage to individuals and small employers will only be allowed to vary premiums based on age, tobacco use, family size, and geography.  Basing premiums on other factors will be illegal.  The factors that are no longer permitted in 2014 include health status, past insurance claims, gender, occupation, how long an individual has held a policy, or size of the small employer.

Guaranteed Renewability
Health insurance companies will no longer refuse to renew coverage because an individual or an employee has become sick.  You may renew your coverage at your option.

Single Risk Pool
Health insurance companies will no longer be able to charge higher premiums to higher cost enrollees by moving them into separate risk pools.  Insurers are required to maintain a single state-wide risk pool for the individual market and single state-wide risk pool for the small group market.

Catastrophic Plans
Young adults and people for whom coverage would otherwise be unaffordable will have access to a catastrophic plan in the individual market.  Catastrophic plans generally will have lower premiums, protect against high out-of-pocket costs, and cover recommended preventive services without cost sharing.

In preparation for the market changes in 2014 and to streamline data collection for insurers and states, the final rule amends certain provisions of the rate review program.  And, HHS has increased the transparency by directing insurance companies in every state to report on all rate increase requests.   A new report has found that the law’s transparency provisions have already resulted in a decline in double-digit premium increases filed: from 75 percent in 2010 to, according to preliminary data, 14 percent in 2013.

In addition, U.S. Department of Labor announced an interim final rule in the Federal Register that provides protection to employees against retaliation by an employer for reporting alleged violations of Title I of the Act or for receiving a tax credit or cost-sharing reduction as a result of participating in a Health Insurance Exchange, or Marketplace

HIPAA - Healthcare Health Insurance

The Health Insurance Portability and Accountability Act of 1996  was enacted by the United States Congress and signed by President Bill Clinton in 1996. It was sponsored by Sen. Nancy Kassebaum .

Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs.
Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers.

A major goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being. The Rule strikes a balance that permits important uses of information, while protecting the privacy of people who seek care and healing. Given that the health care marketplace is diverse, the Rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed.

HIPAA required the Secretary to issue privacy regulations governing individually identifiable health information, if Congress did not enact privacy legislation within three years of the passage of HIPAA. Because Congress did not enact privacy legislation, HHS developed a proposed rule and released it for public comment on November 3, 1999. The Department received over 52,000 public comments. The final regulation, the Privacy Rule, was published December 28, 2000.2

In March 2002, the Department proposed and released for public comment modifications to the Privacy Rule. The Department received over 11,000 comments.The final modifications were published in final form on August 14, 2002.

How can you get Health Insurance Medical Insurance?

Before Buying Health Insurance Medical Healthcare Insurance one must prepare a questioner in his/her mind or should have at least some questions in their mind about why to choose this plan? What is the difference between these two plans ? What benefit I am going to get by opting this plan ? What special is in this plan ? like ways .
I had prepared a list which you may ask to your agent or to health insurance medical insurance company before opting any plan .
We basically know we have plans like Fee for Service Healthcare Insurance Plan, HMO Medical Healthcare Insurance Plan, PPO Health Plan.

 Before opting Fee-for-Service Health Insurance Plans

• How much is the monthly health insurance premium? 
• What will your total cost be each year? There are individual rates and family rates.
• What does the health insurance policy cover? Does it cover prescription drugs, out-of-hospital care, or home care? 
• Are there limits on the amount or the number of days the health insurance provider will pay for these services? The best fee-for-service health insurance plans cover a broad range of health care services.
• Are you currently being treated for a medical condition that may not be covered under your new health insurance plan? Are there limitations or a waiting period involved in the health insurance coverage?
• What is the health insurance deductible? Often, you can lower your monthly health insurance premium by buying a health insurance policy with a higher yearly deductible amount.
• What is the coinsurance rate? What percent of your bills for allowable services will you have to pay
• What is the maximum you would pay out-of-pocket per year? How much would it cost you directly before the health insurance company would pay everything else?
• Is there a lifetime maximum cap the health insurance provider will pay? The cap is an amount after which the health insurance company will not pay anymore. This is important to know if you or someone in your family has an illness that requires expensive treatments. 

Before opting HMO Health Plans

• Are there many doctors to choose from in the HMO plan? Do you select from a list of contract physicians or from the available staff of a group practice? Which doctors are accepting new patients? How hard is it to change doctors if you decide you want someone else?
• How are referrals to specialists handled?
• Is it easy to get appointments? How far in advance must routine visits be scheduled? 
• What arrangements does the HMO have for handling emergency care?
• Does the HMO offer the health care services you want? What preventive services are provided? Are there limits on medical tests, surgery, mental health care, home care, or other support offered? 
• What if you need a special service not provided by the HMO?
• What is the service area of the HMO? 
• Where are the facilities located in your community that serve HMO members? 
• How convenient to your home and workplace are the doctors, hospitals, and emergency care centers that make up the HMO network? 
• What happens if you or a family member are out of town and need medical treatment?
• What will the HMO health insurance plan cost? What is the yearly total for monthly fees? In addition, are there co-payments for office visits, emergency care, prescribed drugs, or other services? How much are they? 

Before opting  PPO Health Plans

• Are there many doctors to choose from in the PPO health insurance plan? Who are the doctors in the PPO network? Where are they located? Which ones are accepting new patients? How are referrals to specialists handled?
• What hospitals are available through the PPO? Where is the nearest hospital in the PPO network? What arrangements does the PPO have for handling emergency care?
• What health care services are covered by the PPO plan? What preventive services are offered? Are there limits on medical tests, out-of-hospital care, mental health care, prescription drugs, or other services that are important to you?
• What will the PPO health insurance plan cost? How much is the premium? 
• Is there a per-visit cost for seeing PPO doctors or other types of co-payments for services? 
• What is the difference in cost between using doctors in the PPO network and those outside it? 
• What is the deductible and coinsurance rate for care outside of the PPO? 
• Is there a limit to the maximum you would pay out of pocket?

Above mentioned questions are some questions which one must definitely ask or get to know before opting any plan . Now comes the question you have opted best available option . Now still you are not sure that you will get maximum benefit from your Medical Healthcare Insurance plan. Below is the thing which we always think after paying for something in this case maximum benefit after opting Health Insurance Plan.


How to Get the Most from Your Health Insurance Plan?

Medicare Vs Medigap in Medical Healthcare Insurance

                                                     Medicare Vs Medigap


Medicare is the federal (national) health insurance program for Americans age 65 and older and for certain disabled Americans. If you are eligible for Social Security or Railroad Retirement benefits and are age 65, you and your spouse automatically qualify for Medicare.

Medicare has two parts: Hospital insurance, known as Part A, and Supplementary medical insurance, known as Part B, which provides payments for doctors and related services and supplies ordered by the doctor. If you are eligible for Medicare, Part A is free, but you must pay a premium for Part B.

Medicare will pay for many of your health care expenses, but not all of them. In particular, Medicare does not cover most nursing home care, long-term care services in the home, or prescription drugs. There are also special rules when Medicare pays your bills that apply if you have employer group health insurance coverage through your own job or the employment of a spouse.

Medicare usually operates on a fee-for-service basis. HMOs and similar forms of prepaid health care plans are now available to Medicare enrollees in some locations.

The best sources of information on the Medicare program are the handbook Medicare & You , and the Medicare website. You may also contact your local Social Security office for information and materials.

Some people who are covered by Medicare buy private insurance, called "Medigap" policies, to pay the medical bills that Medicare does not cover. Some Medigap policies cover Medicare's deductibles; most Medigap policies pay the coinsurance amount. Some Medigap policies also pay for health services not covered by Medicare.

There are 10 standard medical healthcare insurance plans from which you can choose but some States may have fewer than 10. If you buy a Medigap policy, make sure you do not purchase more than one. You need to shop carefully before deciding on the best Medigap policy to fit your needs.

Disability Insurance
Disability insurance replaces income you lose if you have a long-term illness or injury and cannot work. Disability coverage is an important type of insurance for working-age people to consider. Disability insurance does not cover the cost of rehabilitation if you are injured. Check your major medical insurance to see if it is covered there.

Some employers offer group disability insurance and this may be one of the benefits where you work. Or you might be eligible for some government-sponsored programs that provide disability benefits. Many different kinds of individual disability policies are also available.


Hospital Indemnity Insurance
Hospital indemnity insurance offers limited coverage. It pays a fixed amount for each day, up to a maximum number of days. You may use it for medical or other health care expenses. Usually, the amount you receive will be less than the cost of a hospital stay.

Some hospital indemnity policies will pay the specified daily amount even if you have other health insurance. Other hospital indemnity insurance plans may coordinate benefits, so that the money you receive does not equal more than 100 percent of the hospital bill.


Long-Term Care Insurance
Long-term care insurance is designed to cover the costs of nursing home care, which can be several thousand dollars each month. Long-term care is usually not covered by health insurance except in a very limited way. Medicare covers very few long-term care expenses. There are many long-term care insurance plans and they vary in costs and services covered, each with its own limits.

Medical and Health Insurance

Understanding health insurance plans is in reality very complicated. There are many healthcare insurance plans available in market , and deciding which one is best for you is not easy.

Is known that you  have to compromise in some areas. Whether it is cost, variety of health services covered or access to the doctors of your choice, you probably will not get the perfect health insurance plan.

The following points will help you to understand your options.


What Is Most Important to You in a Health Insurance Plan? 
In choosing a health insurance plan, you have to decide what is most important to you. All health plans have trade offs. Ask yourself these questions:

•How comprehensive do you want coverage of health care services to be?
•How do you feel about limits on your choice of doctors or hospitals?
•How do you feel about a primary care doctor referring you to specialists for additional health care?
•How convenient does your health care need to be?
•How important is the cost of health services?
•How much are you willing to spend on health insurance premiums and other health care costs?
•How do you feel about keeping receipts and filing health insurance claims?

You might also want to think about whether the services that a health insurance plan offers meet your needs. Call the health insurance plan for details about coverage if you have questions. As far as i know please consider:

•Life changes you may be thinking about, such as starting a family or retiring.
•Chronic health conditions or disabilities that you or family members have.
•If you or anyone in your family will need health care for the elderly.
•Health care for family members who travel a lot, attend college, or spend time at two homes.


What Health Insurance Plan Benefits Are Offered? 
Most health insurance plans provide basic medical coverage, but the details are what count. The best health insurance plan for someone else may not be the best plan for you. For each health insurance plan you are considering, find out how it handles the following:

•Physical examinations and health screenings.
•Health care by specialists.
•Hospitalization and emergency care.
•Prescription drugs.
•Vision care.
•Dental services.
•Care and counseling for mental health.
•Services for drug and alcohol abuse.
•Obstetrical-gynecological care and family planning services.
•Ongoing care for chronic (long-term) diseases, conditions, or disabilities.
•Physical therapy and other rehabilitative care.
•Home health, nursing home, and hospice care.
•Chiropractic or alternative health care, such as acupuncture.
•Experimental treatments.
•What preventive care is offered, such as shots for children?
•What health screenings are given, such as breast exams and Pap smears for women?

What Are the Health Insurance Costs? 
No health insurance plan will cover every health expense. To get a true idea of what your health care costs will be under each plan, you need to look at how much you will pay for your health insurance premium and other costs.

•Are there deductibles you must pay before the health insurance begins to help cover your costs?
•After you have met your health insurance deductible, what part of your health costs are paid by the plan?
•Does this amount vary by the type of service, doctor, or health facility used?
•Are there co-payments you must pay for certain health services, such as doctor visits?
•If you use doctors outside a plan's network, how much more will you pay to get care?
•If a health insurance plan does not cover certain health services or care that you think you will need, how much will you have to pay?
•Are there any limits to how much you must pay in case of major illness?
•Is there a limit on how much the health insurance plan will pay for your care in a year or over a lifetime? A single hospital stay for a serious condition could cost hundreds of thousands of dollars.

You cannot know in advance what your health care needs for the coming year will be. But you can guess what health services you and your family might need. Figure out what the total costs to your family would be for these services under each health insurance plan.


                            Understanding  Medical Healthcare Insurance Plans

Location of Health Care Services

•Where will you go for care?
•Are these places near where you work or live?
•How does the plan handle care when you are away from home?

Limitations on Health Care Services 
Look at the services offered by each health insurance plan.

•What services are limited or not covered?
•Is there a good match between what is provided and what you think you will need? For example, if you have a chronic disease, is there a special program for that illness?
•Will the plan provide the medicines and equipment you may need?
Find out what types of care or services the plan will not pay for. These are usually called exclusions.


Compare Health Insurance Plans 
After you review what benefits are available and decide what is important to you, you can compare plans. Many things should be considered. These include services offered, choice of providers, location, and costs. The quality of care is also a factor to think about

US Health Insurance Plans

US Health Insurance Plans : HMO, POS, PPO


Managed Care: An Explanation 
You will hear the term "managed care" quite a lot in the United States. It is a way for health insurers to help control costs. Managed care influences how much health care you use. Almost all health insurance plans have some sort of managed care program to help control health care costs. For example, if you need to go to the hospital, one form of managed care requires that you receive approval from your health insurance company before you are admitted to make sure that the hospitalization is needed. If you go to the hospital without this approval, you may not be covered for the hospital bill.


Fee-for-Service Health Plans 
This is the traditional kind of health care policy. Health insurance companies pay fees for the services provided to the insured people covered by the policy. This type of health insurance offers the most choices of doctors and hospitals. You can choose any doctor you wish and change doctors any time. You can go to any hospital in any part of the country.

With fee-for-service health plans, the insurer pays only part of your doctor and hospital bills. You pay a monthly fee, called a premium.

A certain amount of money each year, known as the deductible, is paid for by you before the health insurance payments begin. In a typical plan, the deductible might be $250 for each person in your family, with a family deductible of $500 when at least two people in the family have reached the individual deductible. The deductible requirement applies each year of the health insurance policy. Also, not all health expenses you have count toward your deductible. Only those covered by the health insurance policy do. You need to check the health insurance policy to find out which ones are covered.

After you have paid your deductible amount for the year, you share the bill with the health insurance company. For example, you might pay 20 percent while the health insurer pays 80 percent. Your portion is called "coinsurance".

To receive payment for fee-for-service health claims, you may have to fill out forms and send them to your health insurer. Sometimes your doctor's office will do this for you. You also need to keep receipts for drugs and other medical costs. You are responsible for keeping track of your own medical expenses.

There are limits as to how much a health insurance company will pay for your health claim if both you and your spouse file for it under two different group health insurance plans. A coordination of benefit clause usually limits benefits under two health plans to no more than 100 percent of the claim.

Most fee-for-service health plans have a "cap," the most you will have to pay for medical bills in any one year. You reach the cap when your out-of-pocket expenses (for your deductible and your coinsurance) total a certain amount. It may be as low as $1,000 or as high as $5,000. The health insurance company then pays the full amount in excess of the cap for the items your policy says it will cover. The cap does not include what you pay for your monthly health insurance premium.

Some health services are limited or not covered at all. You need to check on preventive health care coverage such as immunizations and well-child care.

There are two kinds of fee-for-service health coverage: basic and major medical. Basic protection pays toward the costs of a hospital room and health care while you are in the hospital. It covers some hospital services and supplies, such as x-rays and prescribed medicine. Basic coverage also pays toward the cost of surgery, whether it is performed in or out of the hospital, and for some doctor visits. Major medical insurance takes over where your basic coverage leaves off. It covers the cost of long, high-cost illnesses or injuries.

Some health insurance policies combine basic and major medical insurance coverage into one plan. This is sometimes called a "comprehensive plan." Check your health insurance policy to make sure you have both kinds of protection.


HMO: Health Maintenance Organizations 
A health maintenance organization, or "HMO", is a prepaid health plan. As an HMO member, you pay a monthly premium. In exchange, the HMO provides comprehensive health care for you and your family, including doctors' visits, hospital stays, emergency care, surgery, laboratory (lab) tests, x-rays, and therapy.

The HMO arranges for this health care either directly in its own group practice and/or through doctors and other health care professionals under contract. Usually, your choices of doctors and hospitals are limited to those that have agreements with the HMO to provide health care. However, exceptions are made in emergencies or when medically necessary.

There may be a small co-payment for each office visit, such as $5 for a doctor's visit or $25 for hospital emergency room treatment. Your total medical costs will likely be lower and more predictable in an HMO than with fee-for-service health insurance.

Because HMOs receive a fixed fee for your covered medical care, it is in their interest to make sure you get basic health care for problems before they become serious. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. The range of health services covered varies in HMOs, so it is important to compare available HMO plans. Some services, such as outpatient mental health care, often are provided only on a limited basis.

Many people like HMOs because they do not require claim forms for office visits or hospital stays. Instead, members present a card, like a credit card, at the doctor's office or hospital. However, in an HMO you may have to wait longer for an appointment than you would with a fee-for-service health insurance plan.

In some HMOs, doctors are salaried and they all have offices in an HMO building at one or more locations in your community as part of a prepaid group health practice. In others, independent groups of doctors contract with the HMO to take care of patients. These are called individual practice associations (IPAs) and they are made up of private physicians in private offices who agree to care for HMO members. You select a doctor from a list of participating physicians that make up the IPA network. If you are thinking of switching into an IPA-type of HMO, ask your doctor if he or she participates in the HMO plan.

In almost all HMOs, you either are assigned or you choose one doctor to serve as your primary care doctor. This doctor monitors your health and provides most of your medical care, referring you to specialists and other health care professionals as needed. You usually cannot see a health care specialist without a referral from your primary care doctor who is expected to manage the health care you receive. This is one way that HMOs can limit your choice.

Before choosing an HMO, it is a good idea to talk to people you know who are enrolled in the HMO you are considering. Ask them how they like the services and care given.


POS: Point-of-Service Plans
Many HMOs offer an indemnity-type option known as a Point-of-Service or "POS" health care plan. The primary care doctors in a POS plan usually make referrals to other providers in the health plan. But in a POS plan, members can refer themselves outside the plan and still get some coverage.

If the doctor makes a referral out of the network, the health care plan pays all or most of the bill. If you refer yourself to a provider outside the network and the service is covered by the health plan, you will have to pay coinsurance.


PPO: Preferred Provider Organizations 
The preferred provider organization, or "PPO", is a combination of traditional fee-for-service and an HMO. Like an HMO, there are a limited number of doctors and hospitals to choose from. When you use those providers (sometimes called "preferred providers", other times called "network providers"), most of your medical bills are covered.

When you go to doctors in the PPO, you present a card and do not have to fill out forms. Usually there is a small co-payment for each visit. For some health care services, you may have to pay a deductible and coinsurance.

As with an HMO, a PPO requires that you choose a primary care doctor to monitor your health care. Most PPOs cover preventive care. This usually includes visits to the doctor, well-baby care, immunizations, and mammograms.

In a PPO, you can use doctors who are not part of the plan and still receive some health insurance coverage. At these times, you will pay a larger portion of the bill yourself (and also fill out the claims forms). Some people like this option because even if their doctor is not a part of the network, it means they do not have to change doctors to join a PPO.


Even after you purchase a health plan, it is important to learn how to use and manage your health insurance plan, so you get the most out of it. You should also be familiar with other types of health insurance plans that you may encounter or want to consider, such as Medicare, Medigap, disability insurance, hospital indemnity insurance, and long-term care insurance.

Get deep touch in Plans please read page Insurance and Plans.
To know more about Medicare and Medigap please read page Medicare Vs Medigap.

Why you need Medical Insurance?

Question :- Why you need Medical/Healthcare Insurance?


In the United States, if you do not have any healthcare insurance coverage (medical insurance), you have to pay for healthcare out of your own finances at the time of service. This can run into many thousands of dollars for serious illnesses.

You buy health insurance for the same reason you buy other kinds of insurance: to protect yourself financially. With health insurance, you protect yourself and your family in case you need medical care that could be very expensive.

You cannot predict what your medical bills will be. In a good year, your costs may be low. But if you become ill, your bills could be very high. If you have health insurance, many of your costs are covered by a third-party payer, not by you. A third-party payer can be an health insurance company or, in some cases, it can be your employer.

Many people in the United States are enrolled in some sort of managed care health insurance plan. This is an organized way of both providing services and paying for them. Different types of managed care plans work differently and include preferred provider organizations (PPOs), health maintenance organizations (HMOs), point-of-service (POS) plans and fee-for-service plans. More details about these Plans are explained under different section

Individuals enrolled in health care plans pay a monthly or quarterly fee for health insurance coverage as insurance for the time when they will need medical attention. At the time when a service is provided, the health insurance organization pays part or all of the fee, minimizing the amount you have to pay at the time you receive the service.

To know more about medical healthcare insurance please read page Medical Healthcare Insurance.

Medical Healthcare and Medical/Health Insurance

Now come big picture in Healthcare industry and this is Health Insurance . Many of us know something about Health Insurance but almost everyone has something that they may not know.

Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement.


A Health Insurance policy is:

1. A contract between an insurance provider (e.g. an insurance company or a government) and an individual or his/her sponsor (e.g. an employer or a community organization). The contract can be renewable (e.g. annually, monthly) or lifelong in the case of private insurance. 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.
2. Insurance coverage is provided by an employer-sponsored self-funded ERISA(Employee Retirement Income Security Act) plan. The company generally advertises that they have one of the big insurance companies. However, in an ERISA case, that insurance company "doesn't engage in the act of insurance", they just administer it. Therefore ERISA plans are not subject to state laws. ERISA plans are governed by federal law under the jurisdiction of the US Department of Labor. The specific benefits or coverage details are found in the Summary Plan Description. An appeal must go through the insurance company, then to the Employer's Plan Fiduciary. If still required, the Fiduciary’s decision can be brought to the US Department of Labor to review for ERISA compliance, and then file a lawsuit in federal court.

The individual insured person's obligations may take several forms:

Premium: The amount the policy-holder or his sponsor (e.g. an employer) pays to the health plan to purchase health coverage.

Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share.

Co-payment: The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service.  A co-payment must be paid each time a particular service is obtained.

Coinsurance: Instead of, or in addition to, paying a fixed amount a co-payment, the co-insurance is a percentage of the total cost that insured person may also pay.

Exclusions: Not all services are covered. The insured are generally expected to pay the full cost of non-covered services out of their own pockets.

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 maximums. 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 maximums: 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 maximums 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:  A health care provider on a list of providers pre-selected 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.

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.

Explanation of Benefits: A document that may be sent by an insurer to a patient explaining what was covered for a medical service, and how payment amount and patient responsibility amount were determined.

Medical Healthcare - Dental Care

Dental care practitioners

A dental care practitioner is a health worker who provides care and treatment to promote and restore oral health. These include dentists and dental surgeons, dental assistants, dental auxiliaries, dental hygienists, dental nurses, dental technicians, dental therapists, and related professional titles.

Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, the maxillofacial area and the adjacent and associated structures, and their impact on the human body. Dentistry tends to be perceived as being focused primarily on human teeth, though it is not limited strictly to this. Dentistry is widely considered necessary for complete overall health. Doctors who practice dentistry are known as dentists. The dentist's supporting team – which includes dental assistants, dental hygienists, dental technicians, and dental therapists – aids in providing oral health services.

Lets take an example of Maxillofacial.
Oral and maxillofacial surgery is the surgical specialty concerned with the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck.
Consultant specialists working in this area are variously termed oral surgeons, maxillofacial surgeons or oral and maxillofacial surgeons.

So this may come under dental care practitioners and can come under surgical also. This type of treatment are included in most of healthcare insurance policies and plan .

Dentist also encourage prevention of oral disease through proper and regular brushing of teeth and regular checkups. Many studies have proved that gum disease is one of the main factor in increased risk of diabetes , heart disease etc.

About the specialties of dentist different part of world have different opinions. Lets take about world's leading Healthcare Insurance country America (US Healthcare). They recognize nine dental specialties .
Public health dentistry
Endodontics
Oral and Maxillofacial pathology
Oral and Maxillofacial radiology
Oral and maxillofacial surgery
Orthodontics
Pediatric dentistry
Periodontics
Prosthodontics
General dentistry

Medical Healthcare Insurance - Healthcare Providers

The term Healthcare provider is very vast and deep . This term does not limit to providers who are under Medical Healthcare Insurance but they are also those providers who did not participate in one Medical Insurance but can participate in another Healthcare Insurance provided by some other company or organization.

They may be Out of network to one insurance company but In network to some other insurance company. These providers are those doctors , dentist , nurses , surgeons etc who provides us some sort of service when we visit them .

Healthcare service is provided by both practitioners and professionals

Health care practitioners include physicians, dentists, pharmacists (including clinical pharmacists), physician assistants, nurses , midwives, dietitians, therapists, psychologists, chiropractors, clinical officers, phlebotomists, physical therapists, respiratory therapists, occupational therapists, audiologists, speech pathologists, optometrists, emergency medical technicians, paramedics, medical laboratory scientists, medical prosthetic technicians, radiographers, social workers, and a wide variety of other human resources trained to provide some type of health care service. They often work in hospitals, health care centres, and other service delivery points, but also in academic training, research, and administration. Some provide care and treatment services for patients in private homes. Many countries have a large number of community health workers who work outside of formal health care institutions. Managers of health care services, health information technicians, and other assistive personnel and support workers are also considered a vital part of health care teams.

There is long chain which are included under Health practitioners and professionals.
Audiologist or Speech Therapist
Chiropractors
Clinical nurse specialists
Clinical officers
Dentists
Dietitians
Emergency medical technicians
Medical assistants
Midwives
Nurse
Anesthologist
Occupational therapists
Optometrists
Pharmacists
Physicians
Podiatrist
Psychologists
......................There is long list of Health care providers.

Health care practitioners/ Healthcare providers  are commonly grouped into four fields

1) Medical
2) Nursing
3) Dentistry
4) Allied Health Professions

These fields includes skill level and skill specialization .Health professionals are highly skilled workers, in professions that usually require extensive knowledge including university-level study leading to the award of a first degree or higher qualification. This category includes physicians, dentists, nurse practitioners, pharmacists, physiotherapists, optometrists, and others. Allied health professionals, also referred to as "health associate professionals" in the International Standard Classification of Occupations, support implementation of health care, treatment and referral plans usually established by medical, nursing, and other health professionals, and usually require formal qualifications to practice their profession. In addition, unlicensed assistive personnel assist with providing health care services as permitted.


Another way to categorize health care practitioners is according to the sub-field in which they practice, such as mental health care, pregnancy and childbirth care, surgical care, rehabilitation care, or public health.

Mental health practitioners

A mental health practitioner is a health worker who offers services for the purpose of improving an individual's mental health or treating mental illness. These include psychiatrists, clinical psychologists, clinical social workers, mental health nurse practitioners, marriage and family therapists, as well as other health professionals and allied health professions. These health care providers often deal with the same illnesses, disorders, conditions, and issues; however their scope of practice often differs. The most significant difference across categories of mental health practitioners is education and training.

Maternal and newborn health practitioners

A maternal and newborn health practitioner is a health worker who deals with the care of women and their children before, during and after pregnancy and childbirth. These include obstetricians, obstetrical nurses, midwives (including nurse midwives), nurse practitioners, and others. One of the main differences across these professions is the training and authority to provide surgical services and other life-saving interventions. In some developing countries, traditional birth attendants, or traditional midwives, are the primary source of pregnancy and childbirth care for many women and families, although they are not certified or licensed.

Geriatric care practitioners

A geriatric care practitioner plans and coordinates the care of the elderly and/or disabled to promote their health, improve their quality of life, and maintain their independence for as long as possible. They include geriatricians, Geriatric clinical pharmacists, geriatric nurses, geriatric care managers, geriatric aides, and others who focus on the health and psychological care needs of older adults.

Surgical practitioners

A surgical practitioner is a health worker who specializes in the planning and delivery of a patient's perioperative care, including during the anaesthetic, surgical and recovery stages. They may include general and specialist surgeons, anesthesiologists, nurse anesthetists, surgical nurses, clinical officers, operating department practitioners, anaesthetic technicians, surgical technologists, and others.

Rehabilitation care practitioners

A rehabilitation care practitioner is a health worker who provides care and treatment which aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. These include physiatrists, physiotherapists, orthotists, prosthetists, occupational therapists, recreational therapists, audiologists, speech and language pathologists, respiratory therapists, rehabilitation counsellors, physiotherapy technicians, orthotic technicians, prosthetic technicians, personal care assistants, and others.

Dental care practitioners

A dental care practitioner is a health worker who provides care and treatment to promote and restore oral health. These include dentists and dental surgeons, dental assistants, dental auxiliaries, dental hygienists, dental nurses, dental technicians, dental therapists, and related professional titles.

Foot care practitioners

Care and treatment for the foot, ankle, and lower leg may be delivered by podiatrists, pedorthists, foot health practitioners, podiatric medical assistants, podiatric nurse and others.

Public health practitioners

A public health practitioner focuses on improving health among individuals, families and communities through the prevention and treatment of diseases and injuries, surveillance of cases, and promotion of healthy behaviors. This category includes community and preventive medicine specialists, public health nurses, dietitians, environmental health officers, epidemiologists, health inspectors, and others.

Traditional and complementary medicine practitioners

In many societies, practitioners of traditional medicine or alternative medicine are an important primary health care provider, either as integrated within or remaining outside of the formal health care system. These include practitioners in acupuncture, Ayurveda, herbalism, homeopathy, naturopathy, Siddha medicine, traditional Chinese medicine, traditional Korean medicine, and Unani.

Medical Healthcare Insurance - Healthcare Provider

Healthcare can form significant part of countries economy . Healthcare is conventionally regarded as an important determinant in promoting the general health awareness of people around the world. Take example of this worldwide eradication of Smallpox in 1980 - declared by the WHO as the first disease in human history to be completely eliminated by deliberate health care interventions.

So in order to deliver modern Healthcare depends on group of trained professionals. This includes professionals in medicine, dentistry , nursing , allied health along with public health practitioners and community health workers who systematically provide personnel and population based preventive , curative and rehabilitative care services.

What is Healthcare providers and what they do?

A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities.

An individual health care provider (also known as a health worker) may be a health care professional within medicine, nursing, or a field of allied health. Health care providers may also be a public/community health professional. Institutions (also known as health facilities) include hospitals, clinics,primary care centres, and other service delivery points. The practice of health professionals and operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for purposes of quality assurance. Together, they form part of an overall health care system.

These healthcare providers are linked under Medical Healthcare Insurance . When an individual or family or Group or a company takes Medical Healthcare Insurance they will get list of providers and their contact details and location . By this means Healthcare providers can be easily located and contacted . Which in turn very much helpful to one who is in really need .

Please read page Healthcare Providers for deep information about Health care Providers in Medical Insurance or Health Insurance

Medical Healthcare Insurance

Whenever we listen or read term Healthcare or Medical Healthcare or Medical Healthcare insurance we usually come up with thing some kind of health insurance which is of no use for us . The basic reason behind is that we in a year fall ill or prone to disease once or twice that can be treated only by our nearest physician or chemist shop or by taking some pills that also in cheap . So why to pay in this why to take Medical Healthcare Insurance which is costly and starts payment after some time.

But this wrong perception which we had in our mind . The terms Healthcare in Medical Healthcare Insurance  means:-
The prevention, treatment and management of illness and the preservation of mental and physical well being through the services offered by the medical and allied health professionals.

But still these things can be done if we assign local doctor living nearby to our house. Basic definition of Healthcare will not explain you why to take Medical Healthcare Insurance . The word Care in Medical Healthcare Insurance means a lot in our daily life .

Care is the one that mother do for a child, father do for family, government do for citizens, a good friend do to his/her friend and so on . Still care means a lot like services rendered by members of the health professionals for the benefit of a patient .

Admission care in the nursing interventions defined as facilitating entry of a patient into a healthcare facility.
Adult day care a Medical Healthcare services provided for adults with a disability or illness who need partial care and companionship during the day when family members are working or otherwise unable to stay at home with disabled persons.
Ambulatory care healthcare services that are provider on an outpatient basis.
Cesarean section care in the nursing interventions classification defined as the preparation and support of a patient delivering baby by cesarean section.
Emergency care defined as life saving measures in life threatening situations

Now the idea comes up in our mind why to take Medical Healthcare Insurance . This just like that visiting to dentist , you know you should do it but you avoid it till your last breath . Health insurance is an absolute necessity for every individual - young or old .

A Medical Healthcare Insurance is a way of ensuring you and your family against any financial contingency arising due to an unforeseen medical emergency. The average life span of an individual has increased owing to improved medical facilities and increased awareness about one's well being . However at the same time

healthcare and medical costs have also moved like rocket. Also there has been an increase in incidence of medical problems due to lifestyle like stress and eating habits.

You may also like to read Why you need Medical Healthcare Insurance? Please read