Health Insurance in the United States

Health insurance is one of the most important products an American citizen can buy in his or her lifetime. Health in the United States What makes this claim extraordinary is that health insurance is bought in the hopes that it will never be used. We buy health insurance in the event that, should something make us ill or injure us, we will not be forced into debt as a result. We buy hoping for the best but planning for the worst. Insurance agencies insure wishing us the best health as well, for it means we continue to pay into a system we may not ever use. In the simplest terms, a person buys insurance and makes monthly payments to the insurance company essentially for a promise by that company that they will, should their customer need medical attention, pay for the vast majority of it. For them, every day we live healthy is another day of pure profit, but one drastic illness, one tragic accident, and the insurance company is paying far more than they have received. Insurance companies are playing the odds as much as their customers, each side hoping for their own sake that the insurance is never needed.

History

While there was a form of health insurance in the mid-nineteenth century (which would more accurately be called disability insurance) called “accident insurance,” the modern model of health insurance was not around until the mid-twentieth century. Before this model, patients were expected to pay for medical expenses out of pocket. As the cost of practicing medicine was relatively low and malpractice lawsuits were rare, most patients could afford the bills doctors handed them.

Over the past seventy years or so, American citizens have seen drastic changes in health care, from an early pre-paid system with individual hospitals to a nationalized health care system under President Barack Obama.

Health Care Terms

Allowable Fee, or Usual and Customary Reimbursement (UCR): This is the maximum an insurer will pay for a procedure.
Deductible: Money the policyholder must pay before the insurance company starts paying.
External Appeal/External Review: If you are denied coverage for any reason, you can request a review of your case. An external review would be done by an external review organization.
First-level Internal Appeal Process: The second appeal after the policyholder asks the insurance company to reconsider a decision to deny coverage.
Grievance: A complaint by a provider or member about a decision made by a health maintenance organization.
Health Maintenance Organization (HMO): Sets up many different health care services to its customers. It uses the primary doctor as the discerner of a patient’s needs.
Out-of-pocket maximum: The amount of money a co-insurance member must pay before out-of-network claims will be paid.
Point of Service (POS) Plan: Allows a member to choose in-network or out-of-network care. Out-of-network health care usually costs more out of pocket.
Preferred Provider Organization (PPO): A network of doctors has agreed to care for a specially enrolled population at a discounted rate.
Primary Care Physician (PCP): The doctor seen in most cases of illness or injury. This doctor must be seen in order to make referrals to specialists in some cases.
Prompt Pay Complaint: A complaint brought up by insurer or insured regarding late payment.
Referral: Permission from your primary care physician to see a specialist. Often needed for the specialist’s costs to be covered.
Schedule of Allowances: The amount the insurance company is willing to pay for certain procedures.
Specialist: The primary care physician can refer a patient to this doctor if treatment is beyond his or her area of expertise.

Health Care Laws

Emergency Medical Treatment and Active Labor Act (1986)
This law requires hospitals to provide emergency care to anyone regardless of citizenship, legal status, or ability to pay. No one can be denied emergency care under this law.

What It Means to Physicians – What the EMTALA means to your doctor, and therefore to you.
EMTALA Resources – Updates, references and requirements.

Health Insurance Portability and Accountability Act (1996)
Protects people who have lost their job from immediately losing their health insurance as well.

Privacy and Security Rules – Learn how the Privacy and Security rules protect your information.
A Nurse’s Perspective – An overview of the act from the Online Journal of Issues in Nursing.

Medicare Prescription Drug, Improvement, and Modernization Act (2003)
This law protects those citizens who need Medicare, senior citizens, by introducing Part D to their health care, which lowers the cost of prescription medications.

The Law as It Is Written in Congress – Straight from the floor of Congress, know what the act really says.
Medicare Prescription Drug Benefit Timeline – Important dates and deadlines from the act’s inception.

Patient Safety and Quality Improvement Act (2005)
After a scathing 1999 report entitled To Err is Human: Building a Safer Health System told of the dangers of modern health care, this law was enacted to encourage reporting of conditions which may adversely affect a patient.

An Overview of the Law – All the essential information you need to know.
Understanding Patient Safety Confidentiality – Find out how doctor confidentiality is making you safer.

Patient Protection and Affordable Care Act (2010)
This law, enacted by President Obama, is meant to address issues of pre-existing issues denials, prescription drug coverage in Medicare, and extending the Medicare Trust Fund twelve years.

Understanding the New Law – The Affordable Health Care Act: One Year Later
Library of Congress Affordable Care Act – Know what the law actually says in Congress.

Public Health Care

Federal Employees Health Benefits Program
Federal Employees are offered some of the best variety of health care choices afforded to any other type of employee. These benefits are only offered to those who make a living working for the federal government, but many of these services are also available to a member of the private sector. The difference, though, is that the federal employee will have to pay less out of pocket for it.

US Office of Personnel Management – An overview with brochures.
Description and Requirements for FEHBP – Find out how FEHBP is different from other employer-sponsored plans.

Medicaid
People who cannot afford health care, because they have lost their job, just got out of college, or because their job does not offer insurance, can apply for Medicaid. The purpose of Medicaid is to help people in poverty get back on their feet by covering them for a year. By that time, hopefully the Medicaid recipient will be back on his or her feet. If not, this person will have to reapply.

Medicaid Resources – Links and resources for your Medicaid questions.
Medicaid Fast Facts – Spending, background, and further information.

Medicare
This type of insurance is offered by the federal government to people over the age of 65. While there is debate occurring now concerning raising the minimum age, the purpose of Medicare was to help those who were simply too old to work. It is also available for those who are disabled and cannot work.

Further Medicare Information – Enroll, compare health plans and more.
Medicare News and Information – Stay up to date on all Medicare news.

Military Health System/TRICARE
TRICARE is the military’s health care insurance plan and is meant to cover the medical needs of military personnel and their dependents. Their mission is to provide the best health care possible to active duty members. It is also available to retired or non-active duty members.

Compare TRICARE Plans – Connect with other veterans and caregivers.
TRICARE Information and Resources – Health policy overview for veterans.

State Children's Health Insurance Program (SCHIP)
This federal program matches a state’s funds set aside for its families. The program is meant to cover children’s health care if the parents cannot afford it. It can also help cover families who may make barely too much to qualify for Medicaid but not enough to afford private health care.

SCHIP Information and Resources – Links to more resources and means of enrollment.
USDA on SCHIP – How school meals are affected by SCHIP.

Veterans Health Administration
This type of health care is covered by the US Department of Veterans Affairs (VA) by running various VA outpatient clinics. This type of coverage is beneficial because it is aware of the needs of the group it is serving. In fact, the VA was founded specifically to meet those needs.

US Department of Veterans Affairs – Resources and guides for life after service.
Veterans Health Care News – Keep up to date on health information as well as community events.

Private Health Coverage

Health Maintenance Organization (HMO)
An HMO makes contracts with individual hospitals and doctors, after which the doctor will see the policyholder. The doctor or hospital is then reimbursed by the HMO for the services provided. Any company which hires over twenty-five employees must offer an HMO as part of their coverage plan. An HMO uses a doctor to make sure seeing a specialist is necessary by requiring that, for the visit to be covered, the doctor themselves says it is necessary for the member to visit the specialist.

HMO Basics – Learn what you absolutely have to know before making a decision on an HMO.
HMO Information and Resources – In depth information on HMOs, as well as links to governing bodies.

Preferred Provider Organization (PPO)
A PPO is an organization which can provide its members with reduced rates at a participating doctor’s office. This often requires an entrance fee to get in to the organization. This fee is usually given out of pocket and is in addition to any further medical fees.

More Information About PPOs – Answering your questions about preferred provider organizations.
American Association of Preferred Provider Organizations – Becoming a member, informational brochures, and links to more information on PPOs.