Health insurance

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**Health Insurance Basics:**
– Health insurance is a contract between an insurance provider and an individual or sponsor.
– It can be renewable annually, monthly, or lifelong.
– Health care costs covered are specified in writing in a member contract or national health policy.
– In the U.S., there are tax payer-funded and private-funded health insurance types.
– Private-funded plans like ERISA are exempt from state regulations and overseen by USDOL.

**Policy Terms and Obligations:**
– Premium, deductible, co-payment, coinsurance, and exclusions are key terms in health insurance policies.
– Premium is calculated based on factors like age and location.
– Deductible is the out-of-pocket amount before the insurer pays.
– Co-payment is the amount paid before the insurer covers a visit or service.
– Coinsurance is a percentage of the total cost paid by the insured.
– Exclusions include services not covered, which the insured must pay for.

**Health Insurance Coverage Details:**
– Some policies have coverage limits or maximum payment amounts.
– Out-of-pocket maximum ends payment obligation once reached.
– Capitation is a set amount paid by an insurer to a health care provider.
– In-Network Providers offer discounted rates for plan members.
– Out-of-Network Providers may require the patient to pay full costs.

**Provider Relations and Terms:**
– In-Network and Out-of-Network Providers have different cost implications.
– Prior Authorization is required for some medical services.
– Formulary is the list of drugs covered by the insurance plan.
– Explanation of Benefits is a document sent by the insurer detailing services covered.
– Providers may have contracts with insurers for discounted rates.

**International Health Systems Comparison:**
– U.S. health system is most expensive but underperforms.
– U.S. lacks universal health insurance coverage.
– Healthcare in Australia is provided through a mix of public and private systems.
– Canada’s health care system is mainly managed at the provincial level.
China and Cyprus are undergoing significant healthcare reforms to improve access and quality of services.

Health insurance (Wikipedia)

Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among many individuals. By estimating the overall risk of health risk and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization, such as a government agency, private business, or not-for-profit entity.

According to the Health Insurance Association of America, health insurance is defined as "coverage that provides for the payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment".

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