U.S. Health Insurance 101

[HockeyGod]

After reading a recent thread about a member's benefits, I thought I might put my PHD to work and do an overview of insurance as it exists in the U.S. I won't go into any of the nuts and bolts related to health care reform, but rather an overarching look at how insurance works in the U.S. for adults.

Private insurance
The US is based on a private insurance model. An individual (often through an employer) purchases health insurance. If through an employer, typically an employer pays a portion and then individual pays a portion. Private insurance plans are administered by non-profit or for-profit companies.

Medicaid
A federal and state joint program created in 1965 that provides health care coverage for low income individuals. Medicaid is administered by states and is a voluntary program (all states as of 1980 have a Medicaid program). States must provide a minimum benefit set required by the federal government, but have flexibility in additional benefit sets.

Medicare
A federal program created in 1965 that provides health care coverage for people 65+ who have paid into the Medicare system, have end stage renal disease, have ALS, or have been on Social Security Disability Insurance (SSDI) for 24 months. Medicare does not pay for everything and what it does pay for it only pays a portion (approximately 80%). This can be confused with medicare which is Canada's social insurance program.

• Part A: Hospital Insurance - required program
• Part B: Medical Insurance - voluntary and costs
• Part C: Medicare Advantage - a Medicare HMO
• Part D: Prescription Drug Program - voluntary and costs
• Medigap: a private health insurance program that pays for things Medicare doesn't pay for (such as dental and glasses)

State Programs
Many states offer a health care program that is between Medicaid (very low income) and Private Insurance (working/expensive).

Other Terms

• Premium: the monthly amount you pay regardless of whether or not you use your insurance. Think of it like rent.
• Co-Insurance/Payment: the amount you pay that your insurance won't pay. For example, a procedure costs $100, insurance will pay $80, and your co-pay is $20.
• Deductible: the amount you pay out of pocket before your insurance pays.

If anyone wants to add any other information please feel free. If you have any questions also feel free to ask.

I ask again (like my sexual orientation/gender identity thread) that you not use this to debate US health care system...cause that went over so well in that thread  :o

[Braioch]

You know I always wondered what the damn premium was about....

Which reminds me, I need to get some healthcare going for me ::)

Oh!

I ask again (like my sexual orientation/gender identity thread) that you not use this to debate US health care system...cause that went over so well in that thread  :o

Yes, let's keep Alx's claws retracted ;D



You're so helpful Alx ^_^

[HockeyGod]

Oh!
Yes, let's keep Alx's claws retracted ;D

Bad Brai!  ;D

[DarklingAlice]

Very nicely laid out. Thank you, alxnjsh.

[RubySlippers]

Medicaid is not just tied to income many states ,Florida included, have tighter obligations. In my state you can get on if a pregnant woman during your pregnancy and three months afterwards, a child or be determined to be permanently disabled by the state or SSA (if your on SSI your automatically renrollable).

No Insurance/Out-of-Pocket should be covered to these folks either can't get insurance and there are no options or don't have to worry about costs (or don't worry like the young worker that goes without). For this group save the wealthy free clinics, charity care laws that cover hospitals and getting by is what they have to count on.

[HockeyGod]

Medicaid is not just tied to income many states ,Florida included, have tighter obligations. In my state you can get on if a pregnant woman during your pregnancy and three months afterwards, a child or be determined to be permanently disabled by the state or SSA (if your on SSI your automatically renrollable).

Yes, you are right some individuals qualify for Medicaid with co-existing conditions. However, Medicaid is ALWAYS tied to income even in these instances. There also are asset guidelines. The two you pointed out are interesting. SSI is always under the Medicaid eligibility that's why there's an automatic trigger. SSDI can be above the federal poverty level and as such these people qualify for Medicare after having been on SSDI for 24 months. In Florida, to qualify for Medicaid under the pregnancy provision you still must be at 185% of the federal poverty level. Source: http://www.dcf.state.fl.us/programs/access/docs/fammedfactsheet.pdf