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How Health Insurance Works

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Health insurance works by protecting your assets from the high cost of medical care. Without it, your entire life savings could be wiped out by a $300,000 medical bill.It's very complicated, and many people are overwhelmed and annoyed with the process. Here's an explanation of health insurance, and how it got to be the dominant delivery vehicle for health care in America.Health care in the United States can be very expensive. A single doctor’s office visit may cost several hundred dollars and an average three-day hospital stay can run tens of thousands of dollars or even more depending on the type of care provided. Most of us could not afford to pay such large sums if we get sick, especially since we don’t know when we might become ill or injured or how much care we might need. Health insurance offers a way to reduce such costs to more reasonable amounts. 

Healthcare in the United States: The top five things


1.There is no universal healthcare. The U.S. government does not provide health benefits to citizens or visitors. Any time you get medical care, someone has to pay for it.


2.Healthcare is very expensive. According to a U.S. government website, if you break your leg, you could end up with a bill for $7,500. If you need to stay in the hospital for three days, it would probably cost about $30,000.


3.Most people in the U.S. have health insurance. Health insurance protects you from owing a lot of money to doctors or hospitals if you get sick or hurt. To get health insurance, you need to make regular payments called “premiums” to a health insurance company. In exchange, the company agrees to pay some, or all, of your medical bills. 


4.You will get most of your care from your “primary care provider” (PCP). After you buy health insurance, you can choose a PCP who is part of your insurance company’s network. If you buy an MIT health insurance plan, you will choose a PCP at MIT Medical. Your new PCP could be a nurse practitioner or a physician. You will see your PCP when you need a physical exam or lab test, when you are sick, or if you need care for an ongoing condition, like diabetes or high blood pressure.


5.You will usually need an appointment to get medical care. If you want to see your PCP, you will need to call your PCP’s office to make an appointment. When you call, you need to explain why you need the appointment. If you are sick or hurt, you will get an appointment very soon. If you just need a routine physical exam, you might have to wait several weeks or even a month.


How U.S. Health Insurance Works

The way it typically works is that the consumer (you) pays an up front premium to a health insurance company and that payment allows you to share "risk" with lots of other people (enrollees) who are making similar payments. Since most people are healthy most of the time, the premium dollars paid to the insurance company can be used to cover the expenses of the (relatively) small number of enrollees who get sick or are injured. Insurance companies, as you can imagine, have studied risk extensively, and their goal is to collect enough premium to cover medical costs of the enrollees. There are many, many different types of health insurance plans in the U.S. and many different rules and arrangements regarding care.


Where can I receive care?


One way that health insurance plans control their costs is to influence access to providers. Providers include physicians, hospitals, laboratories, pharmacies, and other entities. Many insurance companies contract with a specified network of providers that has agreed to supply services to plan enrollees at more favorable pricing.If a provider is not in a plan’s network, the insurance company may not pay for the service(s) provided or may pay a smaller portion than it would for in-network care. This means the enrollee who goes outside of the network for care may be required to pay a much higher share of the cost. This is an important concept to understand, especially if you are not originally from the local Stanford area.


What does the plan cover?


One of the things health care reform has done in the U.S. under the Affordable Care Act is to introduce more standardization to insurance plan benefits. Before such standardization, the benefits offered varied drastically from plan to plan. For example, some plans covered prescriptions, others did not. Now, plans in the U.S. are required to offer a number of "essential health benefits" which include


    Emergency services

    Hospitalization

    Laboratory tests

    Maternity and newborn care

    Mental health and substance-abuse treatment

    Outpatient care (doctors and other services you receive outside of a hospital)

    Pediatric services, including dental and vision care

    Prescription drugs

    Preventive services (e.g., some immunizations) and management of chronic diseases

    Rehabilitation services


 How much will it cost?  


Understanding what insurance coverage costs is actually quite complicated. In our overview, we talked about paying a premium to enroll in a plan. This is an up front cost that is transparent to you i.e., you know how much you pay.

Unfortunately, for most plans, this is not the only cost associated with the care you receive. There is also typically cost when you access care. Such cost is captured as deductibles, coinsurance, and/or copays see definitions below and represents the share you pay out of your own pocket when you receive care. As a general rule of thumb, the more you pay in premium up front, the less you will pay when you access care. The less you pay in premium, the more you will pay when you access care.

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Important Insurance Terms and Concepts:

Out-of-pocket expenses:The terms "out-of-pocket cost" and/or "cost sharing" refer to the portion of your medical expenses you are responsible for paying when you actually receive health care. The monthly premium you pay for care is separate from these costs.

    Annual deductible: The annual deductible is amount you pay each plan year before the insurance company starts paying its share of the costs. If the deductible is $2,000, then you would responsible for paying the first $2,000 in health care you receive each year, after which the insurance company would start paying its share.

    Copayment (or 'Copay'): The copay is a fixed, upfront amount you pay each time you receive care when that care is subject to a copay. For example, a copay of $30 might be applicable for a doctor visit, after which the insurance company picks up the rest. Plans with higher premiums generally have lower copays and vice versa. Plans that do not have copays typically use other methods of cost sharing.

    Coinsurance: Coinsurance is a percentage of the cost of your medical care. For an MRI that costs $1,000, you might pay 20 percent ($200). Your insurance company will pay the other 80 percent ($800). Plans with higher premiums typically have less coinsurance.

    Annual out-of-pocket maximum: The annual out-of-pocket maximum is the most cost-sharing you will be responsible for in a year. It is the total of your deductible, copays, and coinsurance (but does not include your premiums). Once you hit this limit, the insurance company will pick up 100 percent of your covered costs for the remainder of the plan year. Most enrollees never reach the out-of-pocket limit but it can happen if a lot of costly treatment for a serious accident or illness is needed. Plans with higher premiums generally have lower out-of-pocket limits.

    What is means to be a 'Covered Benefit':


The terms 'covered benefit' and 'covered' are used regularly in the insurance industry, but can be confusing. A 'covered benefit' generally refers to a health service that is included i.e., 'covered' under the premium for a given health insurance policy that is paid by, or on behalf of, the enrolled patient. 'Covered' means that some portion of the allowable cost of a health service will be considered for payment by the insurance company. It does not mean that the service will be paid at 100%.


For example, in a plan under which 'urgent care' is 'covered', a copay might apply. The copay os an out-of-pocket expense for the patient. If the copay is $100, the patient has to pay this amount usually at the time of service and then the insurance plan 'covers' the rest of the allowed cost for the urgent care service.


In some instances, an insurance company might not pay anything toward a 'covered benefit'. For example, if a patient has not yet met an annual deductible of $1,000, and the cost of the covered health service provided is $400, the patient will need to pay the $400 often at the time of service. What makes this service 'covered' is that the cost counts toward the annual deductible, so only $600 would remain to be paid by the patient for future services before the insurance company starts to pay its share.

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Privacy Policy

At Insureandfinanceme, accessible from http://insureandfinanceme.com, one of our main priorities is the privacy of our visitors. This Privacy Policy document contains types of information that is collected and recorded by Insureandfinanceme and how we use it.


If you have additional questions or require more information about our Privacy Policy, do not hesitate to contact us.


This Privacy Policy applies only to our online activities and is valid for visitors to our website with regards to the information that they shared and/or collect in Insureandfinanceme. This policy is not applicable to any information collected offline or via channels other than this website. 


Consent

By using our website, you hereby consent to our Privacy Policy and agree to its terms.


Information we collect

The personal information that you are asked to provide, and the reasons why you are asked to provide it, will be made clear to you at the point we ask you to provide your personal information.


If you contact us directly, we may receive additional information about you such as your name, email address, phone number, the contents of the message and/or attachments you may send us, and any other information you may choose to provide.


When you register for an Account, we may ask for your contact information, including items such as name, company name, address, email address, and telephone number.


How we use your information

We use the information we collect in various ways, including to:


Provide, operate, and maintain our website

Improve, personalize, and expand our website

Understand and analyze how you use our website

Develop new products, services, features, and functionality

Communicate with you, either directly or through one of our partners, including for customer service, to provide you with updates and other information relating to the website, and for marketing and promotional purposes

Send you emails

Find and prevent fraud

Log Files

Insureandfinanceme follows a standard procedure of using log files. These files log visitors when they visit websites. All hosting companies do this and a part of hosting services' analytics. The information collected by log files include internet protocol (IP) addresses, browser type, Internet Service Provider (ISP), date and time stamp, referring/exit pages, and possibly the number of clicks. These are not linked to any information that is personally identifiable. The purpose of the information is for analyzing trends, administering the site, tracking users' movement on the website, and gathering demographic information.


Cookies and Web Beacons

Like any other website, Insureandfinanceme uses 'cookies'. These cookies are used to store information including visitors' preferences, and the pages on the website that the visitor accessed or visited. The information is used to optimize the users' experience by customizing our web page content based on visitors' browser type and/or other information.


For more general information on cookies, please read "What Are Cookies" from Cookie Consent.


Advertising Partners Privacy Policies

You may consult this list to find the Privacy Policy for each of the advertising partners of Insureandfinanceme.


Third-party ad servers or ad networks uses technologies like cookies, JavaScript, or Web Beacons that are used in their respective advertisements and links that appear on Insureandfinanceme, which are sent directly to users' browser. They automatically receive your IP address when this occurs. These technologies are used to measure the effectiveness of their advertising campaigns and/or to personalize the advertising content that you see on websites that you visit.


Note that Insureandfinanceme has no access to or control over these cookies that are used by third-party advertisers.


Third Party Privacy Policies

Insureandfinanceme's Privacy Policy does not apply to other advertisers or websites. Thus, we are advising you to consult the respective Privacy Policies of these third-party ad servers for more detailed information. It may include their practices and instructions about how to opt-out of certain options.


You can choose to disable cookies through your individual browser options. To know more detailed information about cookie management with specific web browsers, it can be found at the browsers' respective websites.


CCPA Privacy Rights (Do Not Sell My Personal Information)

Under the CCPA, among other rights, California consumers have the right to:


Request that a business that collects a consumer's personal data disclose the categories and specific pieces of personal data that a business has collected about consumers.


Request that a business delete any personal data about the consumer that a business has collected.


Request that a business that sells a consumer's personal data, not sell the consumer's personal data.


If you make a request, we have one month to respond to you. If you would like to exercise any of these rights, please contact us.


GDPR Data Protection Rights

We would like to make sure you are fully aware of all of your data protection rights. Every user is entitled to the following:


The right to access – You have the right to request copies of your personal data. We may charge you a small fee for this service.


The right to rectification – You have the right to request that we correct any information you believe is inaccurate. You also have the right to request that we complete the information you believe is incomplete.


The right to erasure – You have the right to request that we erase your personal data, under certain conditions.


The right to restrict processing – You have the right to request that we restrict the processing of your personal data, under certain conditions.


The right to object to processing – You have the right to object to our processing of your personal data, under certain conditions.


The right to data portability – You have the right to request that we transfer the data that we have collected to another organization, or directly to you, under certain conditions.


If you make a request, we have one month to respond to you. If you would like to exercise any of these rights, please contact us.


Children's Information

Another part of our priority is adding protection for children while using the internet. We encourage parents and guardians to observe, participate in, and/or monitor and guide their online activity.


Insureandfinanceme does not knowingly collect any Personal Identifiable Information from children under the age of 13. If you think that your child provided this kind of information on our website, we strongly encourage you to contact us immediately and we will do our best efforts to promptly remove such information from our records.

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