Health insurance is an insurance that covers the whole or part of a person's risk of spending on medical expenses, spreading the risk to a large number of people. By estimating the overall risk of health care and health care costs on risk groups, insurance companies may develop routine financial structures, such as monthly taxes or salary payments, to provide money to pay for the health benefits specified in the insurance agreement. The benefits are managed by central organizations such as government agencies, private businesses, or non-profit entities. According to the American Health Insurance Association, health insurance is defined as "coverage that provides benefit payments as a result of illness or injury, including insurance for accidental losses, medical expenses, disability, or death and unintended deductions" (p 225).
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The health insurance policy is:
- Contracts between insurance providers (eg insurance companies or governments) and individuals or sponsors (eg companies or community organizations). Contracts may be renewed (eg annually, every month) or for life in the case of private insurance, or mandatory for all citizens in the case of a national plan. The type and amount of health care expenses to be borne by the health insurance provider is set out in writing, in a member contract or the book "Evidence Coverage" for personal insurance, or in the national health policy for general insurance.
- (US only) Provided by a self-sponsored ERISA plan by a company-sponsored company. Companies generally advertise that they have one of the major insurance companies. However, in the case of ERISA, the insurance company "is not involved in insurance measures", they are just running it. Therefore, the ERISA plan is not subject to state legislation. The ERISA plan is governed by federal law under the jurisdiction of the US Department of Labor (USDOL). Details of specific benefits or coverage can be found in the Summary of Plan Summary (SPD). Appeals must go through the insurance company, then to the Fiduciary Employer Plan. If still required, the Fiduciary decision can be brought to USDOL to review ERISA compliance, and then file a lawsuit in federal court.
Individual obligations of the insured person may take several forms:
- Premium: The number of policyholders or sponsors (eg employer) pays for a health plan to purchase health coverage.
- Deductible: The amount to be paid by the insured before the health insurance company pays its share. For example, policyholders may have to pay a deductible $ 500 annually, before their health care coverage is covered by health insurers. It may take several doctor visits or refill the recipe before the insured person reaches the deductible and the insurance company starts paying for the treatment. In addition, most policies do not apply to doctors' payments or prescriptions to your deductions.
- Shared payment: The amount payable by an insured person before health insurance pays for a particular visit or service. For example, an insured person can pay $ 45 co-payment for a doctor's visit, or to get a prescription. Combined payments must be paid whenever a particular service is obtained.
- Coinsurance: Instead, or in addition, paying a fixed amount in advance (co-payments), co-insurance is a percentage of the total cost of insured person can also pay. For example, members may have to pay 20% of operating costs above and above joint payments, while insurance companies pay the other 80%. If there is an upper limit on coinsurance, policyholders may end up with very little, or much, depending on the true cost of the services they get.
- Exception: Not all services are included. Billed items such as use-and-throw, taxes, etc. are excluded from claims received. Insured is generally expected to pay the full cost of non-enclosed services from their own pockets.
- Insurance coverage: Some health insurance policies only pay health care up to a certain dollar amount. The insured person can be expected to pay any fees that exceed the maximum payment of the health plan for a particular service. In addition, some insurance schemes have a maximum annual or lifetime coverage. In this case, the health plan will stop paying when they reach the maximum benefit, and the policyholder must pay all remaining costs.
- Maximum out-of-pocket: Similar to the coverage limit, except that in this case, the insured person's payment obligations expire when they reach the maximum out-of-pocket, and health insurance pays all further covered fees. Maximum out-of-pocket can be limited to certain benefit categories (such as prescription drugs) or may apply to all coverage provided during certain benefit years.
- Capitation: The amount the insurance company pays to the healthcare provider, whose providers agree to treat all members of the insurer.
- Network Providers: (U. term) Health care providers in the list of providers pre-selected by the insurer. Insurance companies will offer coinsurance discounts or joint payments, or additional benefits, to plan members to view in-network providers. Generally, providers in the network are providers who have a contract with an insurance company to accept a further discounted rate of "regular and customary" fees paid by an insurance company to a provider outside the network.
- Previous authorization: A certification or authorization granted by an insurance company before medical services occur. Obtaining authorization means that the insurer is obliged to pay for the service, assuming it is in accordance with what is authorized. Many smaller routine services do not require authorization.
- Benefits Explanation: Documents the insurer can send to the patient explaining what is covered for the medical service, and how the payment amount and the amount of patient responsibility are determined.
The prescription drug plan is a form of insurance offered through some health insurance plans. In the US, patients usually pay for copayment and prescription drug parts or all balances for medicines covered in the plan formulary. The plan is routinely part of the national health insurance program. For example, in the province of Quebec, Canada, universal prescription drug insurance is required as part of a public health insurance plan, but can be purchased and managed either through personal or group plans, or through public plans.
Some, if not most, healthcare providers in the United States will agree to charge the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that is not paid by the insurer. Insurance companies pay from network providers according to "fair and custom" fees, which may be less than the regular cost of the provider. The provider may also have a separate contract with the insurance company to accept what is considered a discounted rate or capitation for the provider's standard fee. Usually the patient costs less to use an in-network provider.
Maps Health insurance
Comparison
The Commonwealth Fund, in its annual survey, "Mirror, Mirror on the Wall", compares the performance of health care systems in Australia, New Zealand, the UK, Germany, Canada and the US. The 2007 study found that, although the US System is the most expensive, it consistently underperforms compared to other countries. One difference between the US and other countries in this study is that the US is the only country without universal health insurance coverage.
The Commonwealth Fund completed a thirteenth health policy survey in 2010. A study on the survey "found significant differences in access, cost burden, and issues with health insurance related to insurance design". Of the countries surveyed, the results show that people in the United States have more out-of-pocket expenses, more disagreements with insurance companies than other countries, and more insurance payments being denied; documents are also higher even though Germany has the same high document level.
Australia
The Australian public health system is called Medicare, which provides free universal access to hospital care and medical care outside the subsidized hospital. It is funded by a 2% tax on all taxpayers, an additional 1% levy on high income people, as well as general income.
The private health system is funded by a number of private health insurance organizations. The largest is Medibank Private Limited, which, until 2014, is a government-owned entity, when it is privatized and listed on the Australian Stock Exchange.
Australian health funds can be 'lucky' including Bupa and pens; 'reciprocity' including the Unity of Australia; or 'nonprofit' including GMHBA, HCF, and HBF Health Fund (HBF). Some, such as the Health Police, have limited membership to certain groups, but the majority have open membership. Membership for most health funds is now also available through comparison sites such as moneytime, Compare Markets, iSelect Ltd., Choosi, ComparingExpert, and YouCompare. This comparison site operates on a commission-based basis with their participating health funds. The Private Health Insurance Ombudsman also operates a free website that allows consumers to search for and compare private health insurance products, which include information on pricing and protection levels.
Most aspects of private health insurance in Australia are governed by the 2007 Private Health Insurance Act. Complaints and reporting of the private health industry are conducted by an independent government agency, the Private Health Insurance Ombudsman. The Ombudsman publishes an annual report outlining the number and nature of complaints per health fund compared to their market share
Private health systems in Australia operate on a "community rating" basis, where premiums do not vary solely due to previous medical history, current health conditions, or (in general) their age (but see Lifetime Health Cover below). Balancing this is a waiting period, especially for pre-existing conditions (usually referred to in industry as PEA, meaning "pre-existing disease"). Funds are entitled to impose a waiting period of up to 12 months on benefits for any medical condition of signs and symptoms that exist for the six months ending on the day the person first took out the insurance. They are also entitled to apply a 12-month waiting period for treatment benefits related to obstetric conditions, and a 2-month waiting period for all other benefits when a person first takes private insurance. Funds have the discretion to reduce or eliminate such waiting periods in individual cases. They are also free to not force them to start, but this will place such funds at risk of "adverse selection", attracting disproportionate members of other funds, or from a pool of members who want to join others. fund. It will also attract people with existing medical conditions, who may never take out insurance at all due to a 12 month rejection of benefits due to PEA Regulations. The benefits paid for these conditions will create pressure on the premium for all members of the fund, causing some people to lose their membership, which will lead to a further rise in the premium, and a vicious circle of premium members-a higher leave will occur.
The Australian Government has introduced a number of incentives to encourage adults to take out private hospital insurance. These include:
- Lifetime Health Cover : If someone has not taken out private hospital insurance before July 1 after their 31st birthday, when (and if) they do so after this time, their premium must include a 2% loading per year for each year without hospital cover. Thus, the person who takes the personal cover for the first time at the age of 40 will pay a 20 percent loading. Loading removed after 10 years of hospital cover continuously. Loading applies only to premiums for hospital cover, not for extra (extra) cover.
- Medicare Levy Surcharge : A person whose taxable income is greater than the prescribed amount (in 2011/12 financial year $ 80,000 for single and $ 168,000 for spouse) and who does not have an adequate level of private hospital cover should pay a 1% surcharge above the standard 1.5% Levic Medicare. The reason is that if people in this income group are forced to pay more money in any way, most will opt to buy hospital insurance with it, with the possibility of benefits if they need private hospital treatment - rather than paying it in taxes additional and must meet the cost of their own private hospitals.
- The Australian Government announced in May 2008 that it proposed to increase the threshold, to $ 100,000 for singles and $ 150,000 for families. This change requires legislative approval. Laws to amend legislation have been introduced but not endorsed by the Senate. The modified version was ratified on October 16, 2008. There is criticism that the change will cause many people to lose their personal health insurance, causing further burden on the public hospital system, and a premium increase for those living with private systems. Other commentators believe that the effect will be minimal.
- Private Health Insurance Rebate : The government subsidizes premiums for all private health insurance insurance, including hospitals and additional (extra), by 10%, 20% or 30%, depending on age. The Rudd government announced in May 2009 that in July 2010, Rabat would be tested, and offered on a sliding scale. While this move (which would require legislation) was defeated in the Senate at the time, in early 2011 the Gillard Government announced plans to reintroduce the law after the Opposition lost its balance of power in the Senate. The ALP and the Green Party have long opposed the rebate, calling it a "middle-class welfare".
Canada
Health care is primarily a constitutional responsibility, the responsibility of the provincial government in Canada (the main exception is the responsibility of the federal government for services provided to Aboriginal people covered by the agreement, Canadian Police Mounted, armed forces, and parliamentarians). As a result, each province manages its own health insurance program. The federal government affects health insurance on the basis of fiscal strength - the government is transferring cash and tax points to the provinces to help cover the cost of universal health insurance programs. Under the Canadian Health Act, the federal government mandates and imposes a requirement that everyone has free access to so-called "medically necessary services," defined primarily as treatments delivered by doctors or in hospitals, and nursing care component long term housing. If the province allows doctors or agencies to charge patients for necessary medical services, the federal government reduces its payments to the province for a prohibited cost. Collectively, Canada's public health insurance system in Canada is often referred to as Medicare. This public insurance is funded by taxes from general government revenues, although British Columbia and Ontario charge a compulsory premium at a fixed rate for individuals and families to generate additional income - essentially an additional tax. Private health insurance is permitted, but in six provincial governments only for services not covered by public health plans, such as semi-private rooms or private rooms in hospitals and prescription drug plans. Four provinces allow insurance for services are also mandated by the Canadian Health Act, but in practice there is no market for it. All Canadians are free to use personal insurance for elective medical services such as laser vision correction surgery, cosmetic surgery, and other non-basic medical procedures. About 65% of Canadians have some form of additional private health insurance; many of them accept it through their employers. Private sector services are not paid for by government accounts for nearly 30 percent of total health care spending.
In 2005, the Supreme Court of Canada ruled, at Chaoulli v. Quebec, that the provincial ban on private insurance for health care that is already insured by provincial plans violates the Quebec Rights and Freedom Act, and in particular the section dealing with the right to life and security, if there is a very long waiting time for care, as alleged in this case. The decision does not change the overall pattern of health insurance in Canada but has pushed efforts to address the core issues of supply and demand and the impact of waiting times.
China
French
The national system of health insurance was instituted in 1945, just after the end of the Second World War. It was a compromise between Gaullist and Communist representatives in the French parliament. The Conservative Gaullists oppose state-run healthcare systems, while the Communists support the complete nationalization of health care throughout the British Beveridge model.
The resulting program is profession-based: all working people are required to pay a portion of their income for a non-profit health insurance fund, which balances the risk of illness, and that reimburses the cost of treatment at various levels. Children and spouse of the insured person are also entitled to benefit. Each fund is free to manage its own budget, and is used to reimburse medical expenses with the appropriate rate, but has followed a number of reforms in recent years, most of the funds providing the same level of reimbursement and benefits.
The government has two responsibilities in this system.
- The responsibility of the first government is the setting of tariffs in which medical costs are to be negotiated, and that is done in two ways: the Ministry of Health directly negotiates the price of the drug with producers, based on the average selling price observed in neighboring countries. A board of physicians and experts decides whether the drug provides valuable medical benefits to be replaced (note that most medications are replaced, including homeopathy). Accordingly, the government is improving the rate of reimbursement for medical services: this means that physicians are free to charge the fees they want for consultation or examination, but the social security system will only return them at a predetermined rate. This tariff is set annually through negotiations with a representative organization of physicians.
- The responsibility of the second government is to oversee health insurance funds, to ensure that they manage the amount they receive correctly, and to ensure supervision of public hospital networks.
Currently, the system is more or less intact. All legitimate citizens and legal residents of France are covered by one of these mandatory programs, which continue to be funded by workers' participation. However, since 1945, a number of major changes have been introduced. First, different health care funds (there are five: General, Mandiri, Agriculture, Students, Civil Servants) now all replace at the same rate. Second, since 2000, the government now provides health care to those not covered by the mandatory regime (those who have never worked and who are not students, which means either very rich or very poor). This regime, unlike what is financed by workers, is financed through general taxes and replacements at a higher rate than a profession-based system for those who are unable to make a difference. Finally, to overcome the increase in health care costs, the government has installed two plans, (in 2004 and 2006), which require the insured person to declare a referring physician to be fully reimbursed for specialist visits, and who installs a 1 EUR payment about $ 1.45) for doctor's visit, 0.50 EUR (about 80 Â ¢) for each prescribed medicine box, and costs 16-18 EUR ($ 20-25) per day for hospital stay and for procedure expensive.
The essential element of the French insurance system is solidarity: the more a person becomes ill, the less people pay. This means that for people with serious or chronic diseases, the insurance system replaces them 100% of the cost, and waives their co-paying fees.
Finally, for a fee not covered by the mandatory system, there are a large number of complementary personal insurance packages available. The market for these programs is highly competitive, and is often subsidized by employers, which means that premiums are usually simple. 85% of French people benefit from complementary private health insurance.
German
Germany has the oldest social health insurance system in the world, with its origins dating back to Otto von Bismarck's Sickness Insurance Law of 1883.
Currently 85% of the population is covered by the basic health insurance plan provided by law, which provides standard coverage levels. The rest choose private health insurance, which often offers additional benefits. According to the World Health Organization, Germany's health care system is 77% government-funded and 23% privately funded in 2004.
The government partially reimburses the costs for low-wage workers, whose premiums are limited to the specified value. Higher wage workers pay a premium based on their salary. They can also choose private insurance, which is generally more expensive, but the price may vary based on individual health status.
Reimbursement is on a fee-for-service basis, but the number of doctors who are allowed to receive Health Insurance Statutes in a given location is governed by government and professional societies.
Payments Co. was introduced in the 1980s in an effort to prevent overuse utilization. The average length of stay in hospitals in Germany has declined in recent years from 14 days to 9 days, still much longer than the average stay in the United States (5 to 6 days). Part of the difference is that the primary consideration for hospital replacement is the number of hospital days that conflict with the procedure or diagnosis. Drug costs have increased substantially, increasing by almost 60% from 1991 to 2005. Despite efforts to control costs, overall health care spending increased to 10.7% of GDP in 2005, comparable to other western European countries, but far less than spent in the US. (almost 16% of GDP).
Insurance system
The Germans are offered three types of social security insurance that relate to a person's physical status and which are financed jointly by employers and employees: health insurance, accident insurance, and long-term care insurance.
Germany has a universal multi-payer system with two main types of health insurance: legal health insurance (or public health insurance) (Gesetzliche Krankenversicherung (GKV) and private insurance Private Krankenversicherung (PKV ) ). Both systems are struggling with the rising cost of medical care and demographic changes. About 87.5% of people with health insurance are members of the public system, while 12.5% ​​are insured by private insurers (as of 2006). There are many differences between public health insurance and private insurance. In general, the benefits and costs in private insurance are better for young people without families. There is a difficult salary requirement to join private insurance as it is becoming more expensive in recent years.
Health Insurance Statute/Gesetzliche Krankenversicherung (GKV)
Compulsory health insurance (est. 1883) was part of the German social insurance system, together with legal injury insurance (est. 1883), old age and disability insurance (est. 1889), unemployment insurance (est. ) and long-term care insurance (est. in 1995).
Since 2009, health insurance is mandatory for anyone living in Germany.
Compulsory health insurance is compulsory insurance for employees with annual income below EUR54.900 (by 2015, adjusted annually) and others.
History
With 'Imperial Bill of 15 June 1883' and its update from April 10, 1892 a health insurance bill was created, which introduced compulsory health insurance for workers. Austria followed Germany in 1888, Hungary in 1891 and Switzerland in 1911.
On April 29, 1869, sick local health insurance in Bavaria created the first law to introduce and regulate health insurance for low-income people. It is limited to individuals with incomes of less than 2000 Marks per year and guaranteed the insured person's 60% minimum income during illness.
Function
The function of health insurance under the law Ã, §1 SGB V is to defend, recreate or improve the health of the insured person. According to  27 SGB V this is included to "subdue suffering disease".
All insured basically have the same right to get benefit. The scope of benefits is set out in SGB V ("five social insurance bills") and is limited by SGB V. The benefits shall be adequate, precise and economical and shall not exceed those required for the insured.
Additional benefits can only be granted under special regulations under formal law. These are for example additional services for disease prevention, home care, household support, rehabilitation etc.
Based on the principle of solidarity and compulsory membership, the cost calculation differs from private health insurance because it does not rely on personal health or health criteria such as age or sex, but is connected to a person's personal income with a fixed percentage. The goal is to cover the high cost risks of an unbearable disease of an individual.
Organization
The German legislature has reduced the number of public health insurance organizations from 1209 in 1991 to 123 by 2015.
Public health insurance organizations (health insurance) are substitute funds (EK), Regional Health Insurance (AOK), operations (BKK), union funds (IKK) Miners (KBS), and Agricultural health insurance (LKK).
As long as a person has the right to choose his health insurance, he or she may join any insurance that is willing to enter the individual.
Private health insurance/Private Krankenversicherung (PKV)
Legal accidents insurance/gesetzliche Unfallversicherung
Accident insurance (Unfallversicherung) is protected by the employer and basically covers all risks for leaving for work and at work.
Law enforces long-term care insurance/Gesetzliche Pflegeversicherung
Long-term care (Pflegeversicherung) is covered in half and half by employers and employees and covers cases where a person can not manage his daily routine (food supply, apartment cleaning, personal hygiene, etc.). This is about 2% of the income or pension paid per year, with an employer in accordance with the employee's contribution.
In 2013 state-funded private care insurance is introduced ("Private Pflegeversicherung"). An insurance contract that fits certain criteria is subsidized at 60 Euro per year. It is expected that the number of contracts will increase from 400,000 by the end of 2013 to more than one million in the next few years. These contracts have been criticized by consumer rights foundations.
India
Japanese
There are two main types of insurance programs available in Japan - Employee Health Insurance (???? Kenk? -Hoken), and National Health Insurance (??????? Kokumin-Kenk? -Hoken). National Health Insurance is designed for people who are not eligible to become members of an employment-based health insurance program. Although private health insurance is also available, all Japanese nationals, permanent residents, and non-Japanese with a valid visa of one year or longer must be registered either in the National Health Insurance or Employee Health Insurance.
Dutch
In 2006, the new health insurance system came into force in the Netherlands. This new system avoids two pitfalls of adverse selection and moral hazard associated with traditional forms of health insurance using a combination of regulation and insurance equity pools. The moral dangers are avoided by mandating that insurance companies provide at least one policy that meets the government setting minimum coverage level standards, and all adult residents are required by law to purchase this coverage from the insurance company of their choice. All insurance companies receive funding from an equity pool to help cover this government-mandated coverage fee. The group is run by regulators that collect payroll contributions from employers, which constitute about 50% of all healthcare financing, and government funding to protect people who can not afford health care, which is an additional 5%.
The remaining 45% of health care funds come from publicly paid insurance premiums, in which firms compete in price, although the variation between the various insurance companies that compete is only about 5%. However, insurance companies are free to sell additional policies to provide coverage beyond the national minimum. These policies do not receive funds from an equalization pool, but include additional treatment, such as dental procedures and physiotherapy, which are not paid for by compulsory policies.
Funding from an equity pool is distributed to insurance companies for every person they insure under the required policy. However, high-risk individuals get more from the pool, and low-income people and children under 18 years have fully paid insurance. Therefore, insurance companies no longer find high-risk individual insurance as an unattractive proposition, avoiding the potential for adverse selection problems.
Insurance companies are not permitted to make joint payments, caps, or deductibles, or to refuse coverage to anyone who submits a policy, or to charge anything other than a nationally established and published standard premium. Therefore, everyone who buys the insurance will pay the same price as another person who bought the same policy, and everyone will get at least the minimum coverage level.
New Zealand
Since 1974, New Zealand has had an uninterrupted universal health insurance system for personal injury through the Accident Compensation Corporation (ACC). The ACC scheme covers most of the costs associated with injury treatment acquired in New Zealand (including overseas visitors) regardless of how the injury occurred, and also includes lost income (on 80 per cent of employee pre-injury income) and associated costs for rehabilitation long term, such as home and vehicle modifications to those who are severely injured. Funding from the scheme comes from a combination of employer's paycheck (for work injuries), levies on employee taxable income (for non-employment injury to payroll), levies on vehicle and gasoline licenses (for motor vehicle accidents), and funds from bundles general taxation (for non-employment injuries for children, the elderly, unemployed, overseas visitors, etc.)
Rwanda
Rwanda is one of a handful of low-income countries that has implemented a community-based health insurance scheme to reduce financial barriers that prevent poor people from seeking and receiving needed health services. This scheme has helped reach 90% of the country's population with coverage of health services.
Switzerland
Health care in Switzerland is universal and governed by the Swiss Federal Law on Health Insurance. Health insurance is compulsory for all people living in Switzerland (within three months after taking up residence or being born in this country). It is therefore the same across the country and avoids double standards in health care. Insurers are required to offer this basic insurance to everyone, regardless of age or medical condition. They are not allowed to take advantage of this basic insurance, but can on additional plans.
Universal compulsory coverage provides care in case of illness or accident and pregnancy. Health insurance covers the cost of medical care, treatment and hospitalization of the insured. However, the insured person pays a portion of the cost up to the maximum, which may vary based on individually selected plans, the premium is then adjusted. The entire health care system is geared towards achieving the common goal of improving public health and reducing costs while encouraging individual responsibility.
The Swiss health system is a mix of fully subsidized public and private subsidized systems. Insurance premiums vary from insurance to company, individually selected advantages ( franchise ), the residence of the insured and the extent of additional benefit coverage selected (complementary medicine, routine dental care, semi-privacy or private hospital wards, etc.).
The insured person has the freedom of choice among about 60 recognized and competent health care providers to handle their condition (in their territory) with the understanding that the costs are covered by insurance up to the official tariff rate. There is freedom of choice when choosing an insurance company that pays premiums, usually every month. The insured person pays the insurance premium for the basic plan of up to 8% of their personal income. If the premium is higher than this, the government gives the insured person a cash subsidy to pay an additional premium.
Compulsory insurance may be supplemented by a personal "complementary" insurance policy that enables coverage of several categories of care not covered by basic insurance or to improve the standard of space and services in the case of inpatient care. These may include complementary medicine, routine dental care and inpatient care in private wards, which are not covered by compulsory insurance.
As far as compulsory health insurance is concerned, the insurer can not establish conditions related to age, gender or health status for coverage. Although premium rates may vary from one company to another, they must be identical within the same company to all persons insured of the same age group and region, regardless of gender or health condition. This does not apply to supplementary insurance, in which risk-based premiums.
Switzerland has an infant mortality rate of about 3.6 out of 1,000. The general life expectancy in 2012 is for men 80.5 years compared to 84.7 years for women. This is the world's best number.
United Kingdom
The UK National Health Service (NHS) is a publicly funded health care system that provides protection to all people who normally live in the UK. This is not a strict insurance system because (a) no premiums are collected, (b) costs are not charged at the patient level and (c) unpaid expenses from the pool. However, it achieves the main purpose of insurance that is to spread financial risks arising from health problems. The cost of running the NHS (about Ã, Â £ 104 billion in 2007-8) is met directly from general taxation. The NHS provides the majority of health care in the UK, including primary care, inpatient care, long-term health care, optometrists and dentistry.
Private health care continues in parallel with the NHS, paid for largely by private insurance, but is used by less than 8% of the population, and generally as a top-up to the NHS service. There are many treatments not provided by the private sector. For example, health insurance in pregnancy is generally not covered or covered with a limiting clause. General exemptions for the Bupa scheme (and many other insurance companies) include:
aging, menopause and puberty; AIDS/HIV; allergies or allergic disorders; birth control, conception, sexual problems and gender changes; chronic conditions; complications of excluded or restricted conditions/treatments; recovery, rehabilitation and general nursing care; cosmetics, reconstructive or weight-loss treatments; deaf; dental/oral care (such as patching, gum disease, jaw constriction, etc.); dialysis; medicines and dressings for outpatient use or taking home; drugs and experimental treatment; vision; HRT and bone densitometry; learning difficulties, behavioral and developmental problems; care and repatriation abroad; physical aids and devices; pre-existing conditions or special conditions; pregnancy and childbirth; screening and preventive care; sleep problems and disorders; speech disorder; temporary symptomatic relief. (= exception in exceptional circumstances)
There are a number of other companies in the UK that include, among others, ACE Limited, AXA, Aviva, Bupa, Groupama Healthcare, WPA, and PruHealth. A similar exception applies, depending on the policy purchased.
Recently (2009) the UK Medical Doctors' main representative body, the British Medical Association, adopted a policy statement expressing concern about developments in the UK health insurance market. In the Annual Meeting of Representation previously agreed by the Consultant Policy Group (ie the Senior Doctor) stating that the BMA is "deeply concerned that the policies of some private health insurance companies prevent or restrict the patients making choices about (i) the consultants who treat them; ) hospitals where they are treated, (iii) make top up payments to close the gap between the funding provided by their insurance company and the personal care fee they choose. "This goes to" a call on the BMA to publicize these concerns so that the patient is fully informed when make choices about private health care insurance. " The practice of the insurer deciding which consultant might be seen by the patient as opposed to the doctor or the patient is referred to as the Open Reference. The NHS offers patients a choice of hospitals and consultants and does not charge for its services.
The private sector has been used to increase the capacity of the NHS even though most British public are opposed to such engagement. According to the World Health Organization, government funding covered 86% of overall health care spending in the UK in 2004, with private spending covering the remaining 14%.
Almost one in three patients receiving NHS hospital treatment are uninsured and can have the expenses paid by their insurer. Some personal schemes provide cash payments to patients who opt for NHS care, to impede the use of private facilities. A report, by private health analyst Laing and Buisson, in November 2012, estimates that more than 250,000 operations are performed on patients with private health insurance each year at a cost of  £ 359 million. In addition, Ã,  £ 609 million was spent on medical care or emergency surgery. Private health insurance usually does not cover emergency treatment but subsequent recovery can be paid if the patient is transferred to a private patient unit.
United States
The US health care system relies heavily on private health insurance, which is a major source of coverage for most Americans. In 2012 about 61% of Americans have private health insurance under the Centers for Disease Control and Prevention. The Health Research and Quality Agency (AHRQ) found that in 2011, private insurance was billed for 12.2 million hospital admissions in the US and spent about $ 112.5 billion in aggregate hospital care costs (29% of aggregate cost national). Public programs provide a primary source of coverage for most senior citizens and for children and low-income families who meet certain eligibility requirements. The major public programs are Medicare, the federal social insurance program for the elderly and certain disabled individuals; and Medicaid, are co-funded by the federal and state governments but are managed at the state level, which includes certain low-income children and their families. Together, Medicare and Medicaid accounted for about 63 percent of the cost of a national inpatient hospital in 2011. SCHIP is a federal state partnership that serves certain children and families who are not eligible for Medicaid but who can not afford personal coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Medical Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals.
In the late 1990s and early 2000s, health advocacy companies began to appear to help patients deal with the complexities of the health care system. The complexity of the health care system has caused many problems for the American public. A study found that 62 percent of people who declared bankruptcy in 2007 had unpaid medical costs of $ 1000 or more, and in 92% of these cases medical debt exceeded $ 5000. Nearly 80 percent of those filing for bankruptcy have health insurance. Medicare and Medicaid programs are expected to reach 50 percent of all national health expenditures soon. These and many other factors sparked interest in overhauling the health care system in the United States. In 2010 President Obama signed the Law on Patient Protection and Affordable Care Act. This law includes an 'individual mandate' that every American should have health insurance (or pay a fine). Health policy experts such as David Cutler and Jonathan Gruber, as well as the American health insurance lobby group, America's Health Insurance Plans, argue that this provision is necessary to provide "guaranteed issues" and "community assessments", which address the unpopular features of the American health insurance system such as premium weighting, exceptions to pre-existing conditions, and pre-screening of insurance applicants. During March 26-28, the Supreme Court heard arguments about the validity of the Act. Patient Protection and Affordable Care Act are set to be constitutional on June 28, 2012. SCOTUS stipulates that Congress has the authority to impose an individual's mandate in its taxation powers.
History and evolution
At the end of the 19th century, "accident insurance" became available, operating like modern disability insurance. This payment model continued into the early 20th century in some jurisdictions (such as California), where all laws governing health insurance actually refer to disability insurance.
Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. The company, founded in 1850, offers insurance against injuries arising from train and steam crashes. Sixty organizations offered accident insurance in the US in 1866, but the industry quickly dissolved. Despite previous experiments, the origins of disease coverage in the US effectively came from 1890. The company's first sponsored defect policy was issued in 1911.
Prior to the development of medical cost insurance, patients were expected to pay for health care costs from their own pockets, under what is known as a fee-for-service business model. During the mid-20th century, traditional disability insurance developed into a modern health insurance program. One of the main obstacles to this development is that the initial form of comprehensive health insurance is ordered by the courts for violating the traditional ban on corporate practices of the profession by nonprofit companies. The state legislature should intervene and expressly legalize health insurance as an exception to the traditional rule. Currently, the most comprehensive private health insurance program includes routine medical expenses, prevention, and emergency health care procedures, and most prescription drugs (but this is not always true).
Hospital and medical cost policies were introduced during the first half of the 20th century. During the 1920s, each hospital began offering individual services on a pre-paid basis, leading eventually to the development of the Blue Cross organization. The predecessors of the Health Maintenance Organization (HMO) today date from early 1929, until the 1930s and during World War II.
The Employee Retirement Income Act of 1974 (ERISA) regulates the operation of a health benefit plan if the employer chooses to establish one, which is not required. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) grants the right of former employees to continue coverage under the company's sponsored health benefit plan.
Health plan vs. health insurance
Historically, health care organizations (HMOs) tend to use the term "health plan", while commercial insurance companies use the term "health insurance". Health plans may also refer to subscription-based medical care arrangements offered through HMOs, preferred provider organizations, or service plan points. This plan is similar to pre-paid, prepaid, prepaid and pre-paid prepayment plans. Pre-paid health plans typically pay a fixed number of services (eg, $ 300 in preventive care, a number of days of care or home care in skilled care facilities, number of home health visits, fixed costs of spinal manipulation, etc.). The services offered are usually based on the wisdom of frequent contracting benefactor nurses through managed care entities that provide subscription health plans. This determination may be made either before or after admission (concurrent use review).
There are various options available to employers and employees. There are different types of plans, including savings accounts and health plans with high or low deductibles. Plans that have high deductibles usually cost fewer employees for monthly premiums, but the part they pay for every time they use their insurance, as well as overall deductibles before insurance covers something much higher. These types of plans are good for people who rarely go to doctors and need less health care. However, lower abatement plans are usually more expensive, but they save employees because they have to spend a lot of money on services and care. The latest trend for entrepreneurs is to offer a high-deductible plan, called consumer-driven care plans, because their costs are less overall for the care their employees require, but that is a lower monthly premium for employees.
Comprehensive vs. scheduled
Comprehensive health insurance pays a percentage of hospital fees and doctor fees after deductions (usually applicable to hospital fees) or co-payments (usually applicable to doctors fees, but may apply to some hospital services) covered by the insured. These plans are generally expensive because high potential benefit payments - $ 1,000,000 to $ 5,000,000 are common - and because of the many benefits that are covered.
The scheduled health insurance plan is not intended to replace traditional comprehensive health insurance plans and is more of a basic policy that provides access to daily health care such as going to a doctor or getting prescription drugs. In recent years, this plan has taken the name of "mini-med plan" or association plan. The term "association" is often used to describe them because they require membership in an association that must exist for purposes other than to sell insurance. Examples include the Association of Health Care Credit Union. This plan can provide benefits for hospitalization and surgery, but these benefits will be limited. Scheduled plans are not meant to be effective for disaster events. These plans are much cheaper than comprehensive health insurance. They generally pay a limited amount of allowances directly to the service provider, and payments are based on the "benefit schedule" of the plan. In 2005, "the maximum annual benefits for a scheduled mini-health insurance plan can typically range from $ 1,000 to $ 25,000".
Factors affecting insurance rates
A recent study by PricewaterhouseCoopers that examines the triggers of increasing health care costs in the US shows increased utilization created by increased consumer demand, new treatments, and more intensive diagnostic testing, as the most significant. However, Wendell Potter, a longtime PR representative for the health insurance industry, has noted that the group sponsoring this study, AHIP, is a leading group funded by various insurance companies. People in developed countries live longer. The populations of these countries are already aging, and larger groups of senior citizens require more intensive medical care than younger, healthier populations. Advances in medicine and medical technology can also increase the cost of medical care. Lifestyle-related factors can increase utilization and therefore insurance rates, such as: an increase in obesity caused by inadequate exercise and unhealthy food choices; excessive use of alcohol, smoking, and street drug use. Other factors noted by the PWC study include movements for wider access plans, more expensive technology, and the transfer of fees from Medicaid and non-insured payers to the private.
Other researchers note that physicians and other health care providers are rewarded for treating patients rather than curing them and that the insured patients through employer group policies have an incentive to go to the absolute best HCP than the most cost-effective.
Military
The price of health insurance for retired and active military personnel has risen from $ 19 billion a decade ago to $ 52 billion in 2012. TRICARE, the government's veteran health insurance program, makes up nine percent of the total budget for the Department of Defense.
California
In 2007, 87% of Californians had some form of health insurance. Services within the California range of private offers: HMO, PPO for public programs: Medi-Cal, Medicare, and Healthy Families (SCHIP).
California develops solutions to help people across the state and is one of the few states with offices dedicated to providing people with tips and resources to get the best possible care. The California Office of Employee Advocacy was established in July 2000 to issue an annual Health Care Quality Report Card at HMOs, PPOs and leading Medical Groups and to create and distribute useful tips and resources to give California people the tools needed to get the best care possible.
In addition, California has a Help Center that helps Californians when they have problems with their health insurance. The Help Center is run by the Managed Health Care Department, the government department that oversees and regulates HMOs and some PPOs.
Massachusetts
The state passed health reforms in 2006 to further reduce uninsured rates among its citizens. Federal Patient Protection and Affordable Care Act (colloquially known as "Obamacare") are largely based on Massachusetts health reform. Because of that colloquialism, the Massachusetts reforms have been dubbed the "Romneycare" after then -Governor Mitt Romney.
By 2017, Massachusetts has the highest level of insured population in the United States at 97%.
Standard hospitals and clinics used by insurance companies
In the US, insurance companies will often only use healthcare providers independently surveyed by recognized quality assurance programs, such as accredited by accreditation schemes such as the Joint Commission and the American Accreditation Commission on Health.
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See also
References
Source of the article : Wikipedia
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