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| Resource Center | An Insurance Overview |
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Find out about public and private payors and their coverage policies.
PUBLIC PAYORS
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| Medicare |
Medicare is a health insurance program sponsored by the federal government that provides coverage for:
- People aged 65 and older
- People under age 65 with certain disabilities
- People of all ages with End-Stage Renal Disease
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| Medicare has: |
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Part A Hospital Insurance
Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical-access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home healthcare. Beneficiaries must meet certain conditions to get these benefits.
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Part B Medical Insurance
Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists, and some home healthcare. Part B helps pay for these covered services and supplies when they are medically necessary.
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Prescription Drug Coverage
Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.
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| Medicaid |
Medicaid is available only to certain low-income individuals and families who fit into an eligible group that is recognized by federal and state law. Medicaid sends payments directly to your healthcare providers. Depending on your state's rules, you may also be asked for a copayment.
Each state administers its own program and has the responsibility to:
- Establish eligibility standards
- Determine the type, amount, duration, and scope of services
- Set the rate of payment for services
- Administer payment and enrollment systems
Source: http://cms.hhs.gov/, The Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health & Human Services.
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PRIVATE PAYORS
Health insurance plans are usually described as either indemnity (fee-for-service) or managed care. These types of plans differ in important ways as described below.
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| Indemnity Plan (fee-for-service): |
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Indemnity plans allow the insured patient to use any medical provider. The medical provider bills the insurance company. Usually, insurance companies require that a deductible be paid by the insured patient each year before they start paying. Once the deductible is met, most indemnity plans pay a percentage of what they consider the "Usual and Customary" charge for covered services.
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| Managed Care |
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A Preferred Provider Organization (PPO) is a form of managed care closest to an indemnity plan. A PPO has arrangements with doctors, hospitals, and other providers of care who have agreed to accept lower fees from the insurer for their services. As a result, the insured patient’s cost sharing should be lower in-network than outside the network. In addition to the PPO doctors making referrals, plan members can refer themselves to other doctors, including ones outside the plan.
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Health Maintenance Organizations (HMO) are the oldest form of managed care plans. HMOs offer members a range of health benefits, including preventive care, for a set monthly fee. HMOs will provide a list of doctors from which to choose a primary care doctor. The primary care doctor coordinates the insured patient’s care and refers the patient to specialists. Copayments vary by HMOs. HMO plans only cover the cost of charges for doctors in that HMO. When patients utilize Medicare providers outside the HMO, they are responsible for paying the bill.
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Point-of-Service (POS) Plan is an indemnity-type option offered by many HMOs. The primary care doctors in a POS plan usually make referrals to other providers in the plan. But in a POS plan, members now can refer themselves outside the plan and still get some coverage. If the doctor makes a referral out of the network, the plan pays all or most of the bill. If the patient refers himself to a provider outside the network and the service is covered by the plan, the patient will have to pay coinsurance.
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Source: www.ahrq.gov, Agency for Healthcare Research and Quality, United States Department of Health & Human Services. |
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