HEALTH INSURANCES 2019

WHAT IS HEALTH INSURANCE

Health insurance covers medical expenses for illnesses, injuries and conditions. But, unlike a plan through an employer, individual health insurance is something you select and pay for on your own. So, what’s health insurance for and why do you need it?

Because accidents or health problems can happen at any time
Medical expenses can be high—they’re the number one cause of bankruptcy
To gain access to a network of doctors and hospitals that have negotiated lower rates with insurance companies
To pay and keep track of medical payments quickly and easily
To safeguard your way of life and your family’s physical and financial wellbeing

 

 Insurance companies calculate the likelihood and costs of various and multiple medical treatments for which they will be liable, and set an annual rate of premium to be paid by the policyholder. In the United States, the majority of medical provider payments are made under a “fee for service” basis, whereby the provider is compensated based upon the type and number of services rendered to a patient, rather than the outcome of the services.

There are presently efforts within the healthcare community to use patient outcomes as the basis for payment, a method which many believe will lower costs while improving care. However, replacing the existing reimbursement system is likely to take years. In other words, we can continue to expect the fee-for-service model to dominate healthcare for some time.

Why You Need Health Insurance

Health insurance is necessary for Americans to pay for the high cost of health care. You need it unless you are very wealthy, over 65, or very poor. The very wealthy can afford the cost of even extraordinary emergency or chronic medical care. Those over 65 have paid into Medicare. The very poor can qualify for Medicaid.


Everyone else must either purchase health insurance or risk medical bankruptcy. Since it is so common, many people have lost sight of its underlying purpose. It's just like insurance for your car, home, or apartment. It's supposed to protect your life savings from the devastating costs of a major accident, medical emergency, or a chronic disease.

But, unlike other insurance, health insurance makes it possible for you to get that health care when you need it. If you don't have car insurance, you can take the bus until you can afford to get your car fixed. If you break your leg, you can’t splint it yourself until you save up enough to go to the doctor.

TYPES OF HEALTH INSURANCE


Health Maintenance Organization (HMO)
An HMO delivers all health services through a network of healthcare providers and facilities. With an HMO, you may have:

The least freedom to choose your health care providers
The least amount of paperwork compared to other plans
A primary care doctor to manage your care and refer you to specialists when you need one so the care is covered by the health plan; most HMOs will require a referral before you can see a specialist.


Point-of-Service (POS)
Point-of-service plans are similar to PPOs, but they introduce the gatekeeper, or Primary Care Physician. You'll need to choose your PCP from among the plan's network of doctors.

As with the PPO, you can choose to go out of network and still get some kind of coverage. In order to get a referral to a specialist, though, you usually must go through your PCP. You can still choose to refer yourself, but it'll mean more hassles and more money coming out of your pocket. If your PCP refers you to a doctor who is out of the network, the plan should pick up most of the cost.
But if you refer yourself out, then you'll probably have to deal with more paperwork and a smaller reimbursement. You may also have to pay a deductible if you go outside the network.

Preferred Provider Organization (PPO)


A PPO plan is a Preferred Provider Organization group health insurance policy.

With a PPO plan, employees are encouraged to use a network of preferred doctors and hospitals. These providers are contracted to provide service to plan members at a negotiated or discounted rate. Employees generally aren't required to designate a primary care physician, but will have the choice to see any doctors or specialists within the plans network.

Employees have an annual deductible they'll be required to meet before the insurance company begins covering their medical bills. They may also have a copayment for certain services or a co-insurance where they're responsible for a percentage of the total charges of their medical expenses.

With a PPO, services rendered outside of the network may result in a higher out-of-pocket cost.

A PPO may be a good option for your small business if your employees:

Need flexibility when choosing physicians and other providers
Want the burden of obtaining a referral to see a specialist
Like the balance of greater provider choice versus lower premiums


Exclusive Provider Organization (EPO)

A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).

Traditional Health Insurance
Up until about 30 years ago, most people had traditional indemnity coverage. These days, it's often known as "fee-for-service." Indemnity plans are a bit like auto insurance: you pay a certain amount of your medical expenses up front in the form of a deductible and afterward the insurance company pays the majority of the bill.

Advances in modern medicine increased the cost of providing health care and made it possible for people to live longer. Those advances caused many insurance companies to look for ways to reduce their costs of doing business, giving managed care the boost it enjoys today.

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Top 25 U.S. Health Insurance Companies, By Market Share

1.  
   Unitedhealth Group
2.  
   Wellpoint Inc. Group
3.  
   Kaiser Foundation Group
4.  
   Humana Group
5.  
   Aetna Group
6.  
   HCSC Group
7.  
   Cigna Health Group
8.  
   Highmark Group
9.  
   Coventry Corp. Group
10.  
    HIP Insurance Group
11.  
    Independence Blue Cross Group
12.  
    Blue Cross Blue Shield of New Jersey Group
13.  
    Blue Cross Blue Shield of Michigan Group
14.  
    California Physicians' Service
15.  
    Blue Cross Blue Shield of Florida Group
16.  
    Health Net of California, Inc.
17.  
    Centene Corp. Group
18.  
    Carefirst Inc. Group
19.  
    Wellcare Group
20.  
    Blue Cross Blue Shield of Massachusetts Group
21.  
    UHC of California
22.  
    Lifetime Healthcare Group
23.  
    Cambia Health Solutions Inc.
24.  
    Metropolitan Group
25.  
    Molina Healthcare Inc. Group