Tags | USA Health Insurance, US health insurance system, USA health insurance plans, us health insurance overview, US health insurance terminology, USA health insurance basics, USA health insurance coverage

US Health Insurance Overview

In the previous US healthcare article, I have US Healthcare System Overview and How does American Healthcare System Work. Along with that I have given a brief of US healthcare terms. In this a blog post I will discuss USA health insurance basics, US health insurance system and how does the US health insurance system work.

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Health insurance is a type of insurance coverage that covers the cost of an insured individual’s medical and surgical expenses. It depends on the type of health insurance coverage. In the United States, health insurance is any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance or a social welfare program funded by the government.

US Health Insurance System – A Classification

US Health Insurance is divided into Public/Government and Private sectors. Find the structure below:-

• Public/ Government

  • Medicare
  • Medicaid

• Private

  • Employee-sponsored
    • Managed Care
      • HMO
      • PRO
      • EPO
      • POS
    • Free for service
  • Individually Purchased 
    • Managed Care
      • HMO
      • PRO
      • EPO
      • POS
    • Free for service

Let’s discuss first Public or Government type of health insurance. Now, we will see what is the difference between Medicare and Medicaid.

Medicare

• Medicare is a Federal Insurance program
• Eligibility:
  • People who are
    • 65 or older
    • Under 65 with certain disability (Amyotrophic lateral sclerosis disease)
    • of any age and having to end-stage renal disease

Medicaid

• Medicaid is a joint Federal and State Program
• Eligibility:
  • Low income
    • Pregnant
    • Children under 19
    • People who are 65+
    • Those people who are blind
    • People who are disabled
    • Those people who need nursing home care

Managed Care Plan Types

Managed health care plans provide a health insurance policy to individual members of a group or employer. The group or employer is the plan sponsor of the managed care plan. A managed health care plan will help beneficiaries (members of the plan) by getting them more favorable rates or discounted medical insurance services from their plan’s health provider network.

Managed care: An agreement between an insurer and specific supplier to give health care at a reduction to a member of an insured group. Let’s discuss one by one:

HMO

• Health Maintenance Organization
• A more restricted and managed care
• Must stay in Network
• Must select a Preferred care Physician (PCP)
• Low-cost sharing
• File claim paperwork not required

EPO

• Exclusive Provider Organization
• A broader, less managed care
• Must stay in Network
• Low-cost sharing
• Not required File claim paper-work

PPO

• Preferred Provider Organization
• A less managed care
• Not require staying in Network
• Need not select a PCP
• Cost sharing is high
• File claim the paperwork only for out-of-network claims

POS

• Point of Service
• A managed care
• Not require staying in Network
• Must select a PCP
• Cost sharing is low for in-network and high for out-of-network
• File claim-paperwork only for out-of-network claims

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