Health insurance in the United States

Question

This piglix contains articles or sub-piglix about Health insurance in the United States

Answer 1

Explanation of benefits

An explanation of benefits (commonly referred to as an EOB form) is a statement sent by a health insurance company to covered individuals explaining what medical treatments and/or services were paid for on their behalf.

The EOB is commonly attached to a check or statement of electronic payment.

An EOB typically describes:

EOB documents are protected health information.

Electronic EOB documents are called edi 835 5010 files.

There normally also will be at least a brief explanation of any claims that were denied, along with a point to start an appeal.

A member with secondary insurance gives such information to the provider for the next bill to go out to that insurance company. Generally, secondary insurance pays only the amount the EOB says the member is responsible for. Secondary EOBs show if the patient still has any responsibility to the provider. After the member's insurances have processed the claim, the provider bills the member for the remaining balance, if any.

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Answer 2

Extended Care Health Option

The Extended Care Health Option or ECHO is a supplemental coverage program offered by TRICARE to dependents of members of the Uniformed services of the United States with a qualifying disability.

ECHO benefits are available with a qualifying condition to a TRICARE-eligible child or spouse of an active duty uniformed service member.

The following are qualifying conditions under ECHO:

TRICARE ECHO requires all eligible beneficiaries do the following:

For more information about the EFMP, Department of Defense beneficiaries may visit the Military Homefront Website. U.S. Coast Guard beneficiaries should contact their regional Work-Life office to inquire about the Coast Guard Special Needs Program.

In addition to coverage received via the primary TRICARE plan, TRICARE ECHO benefits may include:

The ECHO benefit provides a government cost-share limit of $2,500 per month, per eligible family member. In addition to other TRICARE ECHO benefits, beneficiaries who are homebound may qualify for extended in-home health care services. The $2,500 cost share does not apply to the ECHO Home Health Care (EHHC) as there is a benefit cap.

For certain benefits, ECHO requires recipients to first use public funds and facilities to the extent that they are available and adequate.

Under ECHO, sponsors must pay part of the monthly authorized expenses for their family members, based on their pay grade, ranging from $25 to $75 a month for all enlisted and most officers.

The program was originally authorized in Section 701(g) of the National Defense Authorization Act for Fiscal Year 2002 (Public Law 107-107) and is codified in law in 10 USC 1079 (d) through (g). Department of Defense regulations for the ECHO program are found at 32 CFR 199.5 after being published in the August 20, 2004 Federal Register (69 FR 51559).

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Answer 3

Federal Employees Health Benefits Program

The Federal Employees Health Benefits (FEHB) Program is a system of "managed competition" through which employee health benefits are provided to civilian government employees and annuitants of the United States government. The government contributes 72% of the weighted average premium of all plans, not to exceed 75% of the premium for any one plan (calculated separately for individual and family coverage).

The FEHB program allows some insurance companies, employee associations, and labor unions to market health insurance plans to governmental employees. The program is administered by the United States Office of Personnel Management (OPM).

The program was created in 1960. Employer sponsorship of health insurance in the United States became prevalent during World War II, as one of the few ways by which employers could escape wage and price control limitations on employee wages. The government originally proposed a system that would revolve around a dominant government-directed plan, but unions and employee associations, which had sponsored their own plans, protested. Reflecting the political pressure thus created, the Congress modified the Executive Branch proposal and all existing plans were "grandfathered" into the program. Thus, through what was essentially a historical accident and a political compromise, a system of competition among health plans driven by consumer choices was created.

Choices among health plans are available to employees during an "open enrollment" period, or "open season," after which the employee will be covered fully in any plan he or she chooses without limitations regarding pre-existing conditions. After the annual enrollment, changes can be made only upon a "qualifying life event" such as marriage, divorce, adoption or birth of a child, or change in employment status of a spouse, until the next annual open season, during which employees can enroll, disenroll, or change from one plan to another. The exact dates of the open season change from year to year, but are usually from the Monday of the second full week in November through Monday, the second full week of December. Enrollment begins at or near the beginning of the calendar year, and lasts until a different plan choice is made in a subsequent open season or through a qualifying life event. In practice, there is a great deal of inertia in enrollment, and only about 5 percent of employees change plans in most open seasons.

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Answer 4

Healthsouk

HealthSouk is the nation’s first health plan without monthly fees. It is the a real-time pricing model for health services where fees update every 60 seconds. It allows medical providers to list their prices for different procedures as well as available appointment times. In addition, providers may discount prices for individual appointment slots to increase client demand.

Unlike discount plans or medical insurance, the patient does not pay any upfront cost to participate. In addition, the healthcare provider is never charged a monthly fee.

HealthSouk was founded as The Smart Alternative to Dental Insurance and also trademarked as The Smart Dental Insurance Alternative. Both have been actively used by HealthSouk in commerce since its founding in 2011. In 2011, Dr. Neilesh Patel founded Healthsouk in Mountain View, California. He is credited as being the inventor of real-time pricing model of health services. Before starting HealthSouk, Dr. Patel founded Healthcare Volunteer. The first market for HealthSouk was Las Vegas followed by Los Angeles, Orange County and the San Francisco Bay Area. Patel started HealthSouk after seeing Las Vegas patients struggle to access basic and cosmetic dental care during the aftermath of the U.S. housing crisis and stock market crash. The name HealthSouk was named when Patel was visiting the Souks (or marketplaces) of Morocco.

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Answer 5

The Hospital Uninsured Patient Discount Act (Illinois)

The Hospital Uninsured Patient Discount Act (210 ILCS 89) is an Illinois law that requires hospitals in Illinois to give most uninsured patients a discount on their medical bills. The act took effect on April 1, 2009.

It is the patient's responsibility to apply for this discount within 60 days of receiving their bill. The bill must contain information about how to apply.

Almost any uninsured patient may apply for this discount. In order to apply a person must earn less than six times the Illinois poverty line. For example, a patient in a family of four is eligible for this discount if the value of the family's income (including some assets) is less than $132,300 (six times the Illinois poverty line for a family of four). The discount is based on a sliding scale.

A person eligible for the discount will receive a 70% discount if the family income is six times the poverty line, 75% for 4.01 to 5 times the poverty line, 80% for 3.01 to 4 times the poverty line, 90% for 2.01 to 3 times the poverty line, and a 100% discount for those who earn double the poverty line or less. The poverty line is based on family size, income, and some assets.

{as of | 2011} the following qualifies as "below the poverty line" in the state of Illinois:

Many problems with this bill have been noted. One of the most common critiques is that the bill requires a person to prove that they live in the state of Illinois, which can be difficult for someone who is homeless. Another problem with the bill is that it does not address people who have jobs that require health insurance plans through the company. This is an issue as some people in Illinois complain that if they were not required to get health insurance through their work (which might offer a mediocre plan), they would be able to have more coverage under this act. Some people who have insurance through work may have to pay for their plan and pay more of each medical bill as well. Thus for some, these required health care plans actually cost more than not having one.

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Answer 6

Highmark

Highmark Inc.

Highmark is a private healthcare company based in Pittsburgh, Pennsylvania, United States. It is the largest health insurer in Pennsylvania, and through a purchase in 1996, the largest health insurer in West Virginia and also later Delaware. As Highmark Blue Cross Blue Shield, it primarily serves the 29 counties of western Pennsylvania. As Highmark Blue Shield, it serves 21 counties in Central Pennsylvania and the Lehigh Valley. There is also a presence in the border areas of eastern Ohio, and all of West Virginia through its subsidiary, Highmark Blue Cross Blue Shield West Virginia. Highmark acquired the largest health insurer in northeastern Pennsylvania, Blue Cross of North East Pennsylvania, BCNEPA, in July 2015. It is currently the largest individual not-for-profit health insurer in the United States, which operates several for-profit subsidiaries.

Highmark was created in 1977 and in the 1990s by the consolidation of two Pennsylvania licensees of the Blue Cross and Blue Shield Association — Pennsylvania Blue Shield (now Highmark Blue Shield) based in suburban Harrisburg, and Blue Cross of Western Pennsylvania based in downtown Pittsburgh (now Highmark Blue Cross/Blue Shield). The consolidated group serves 49 of the state's 67 counties. In West Virginia, the company operates as Highmark Blue Cross Blue Shield West Virginia, and in Delaware, it operates as Highmark Blue Cross Blue Shield Delaware. The new company based its head offices in downtown Pittsburgh and features greatly expanded services.

On March 28, 2007, Highmark announced it intended to consolidate with Independence Blue Cross of Philadelphia. The combination of the 2 insurers would have created a new company with over 18,000 employees, dual-headquarters in both Pittsburgh and Philadelphia and an economic impact of over $4 billion throughout the Commonwealth of Pennsylvania. On January 22, 2009, Highmark and Independence Blue Cross withdrew their applications to consolidate due to the unacceptability of conditions that the Pennsylvania Insurance Department was going to place upon the merger: to give up either of their well-known "Blue Cross" or "Blue Shield" trademarks.

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Answer 7

Fidelis Care

Fidelis Care

The New York State Catholic Health Plan, d/b/a Fidelis Care, d/b/a Fidelis Care New York provides health insurance coverage to people of all ages in New York State. Formed in 1993 as the Catholic Health Services Plan of Brooklyn and Queens, Inc., Fidelis Care has grown to provide services to more than 1,450,000 New York State residents. Its primary focus is to provide free or low-cost quality health insurance that covers a variety of services and benefits for children and adults of all ages who qualify. Fidelis Care's main offices are located in New York City, Albany, Syracuse, and Buffalo, with satellite offices in Poughkeepsie, Rochester, and Suffern.

Fidelis Care was formed in 1993 under the auspices of the Catholic Medical Center of Brooklyn and Queens, Inc. and the Diocese of Brooklyn to serve the poor and medically underserved, initially operating only in a 14-zip code area Brooklyn. In 1994, Fidelis Care expanded its services throughout Brooklyn and Queens.

In 1994, the eight bishops of the Catholic Dioceses, led by John Cardinal O'Connor, sought to extend the Fidelis Care license across the State, receiving final approval in 1996. In addition to its Medicaid Managed Care program, Fidelis Care became an approved provider of Child Health Plus in 1997, and Family Health Plus in 2001. Both are New York State-sponsored health insurance programs. In May 2004, Fidelis Care began Fidelis Medicare Advantage and Dual Advantage to serve the elderly.

After becoming a subsidiary of Fidelis Care in 2005, CenterCare, a New York City-based Medicaid managed care plan, was formally acquired by Fidelis Care in 2008.

In 2009, Fidelis Care launched Fidelis Medical Advantage Plus (HMO), a managed long term care product for individuals 18 years of age or older who have a chronic illness or disability.

In 2012, Fidelis Care expanded its "Fidelis Care at Home" managed long-term care program into 11 counties throughout New York State.

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Answer 8

HealthCare.gov

HealthCare.gov

HealthCare.gov is a health insurance exchange website operated under the United States federal government under the provisions of the Patient Protection and Affordable Care Act (ACA, often known as 'Obamacare'), designed to serve the residents of the thirty-six U.S. states that opted not to create their own state exchanges. The exchange facilitates the sale of private health insurance plans to residents of the United States and offers subsidies to those who earn less than four times the federal poverty line. The website also assists those persons who are eligible to sign up for Medicaid, and has a separate marketplace for small businesses.

The October 1, 2013 roll-out of HealthCare.gov went through as planned, despite the concurrent partial government shutdown. However, the launch was marred by serious technological problems, making it difficult for the public to sign up for health insurance. The deadline to sign up for coverage that would begin January 2014 was December 23, 2013, by which time the problems had largely been fixed. The open enrollment period for 2016 coverage ran from November 1, 2015 to January 31, 2016. State exchanges also have had the same deadlines; their performance has been varied.

The design of the website was overseen by the Centers for Medicare and Medicaid Services and built by a number of federal contractors, most prominently CGI Group of Canada. The original budget for CGI was $93.7 million, however this grew to $292 million prior to launch of the website. While estimates that the overall cost for building the website had reached over $500 million prior to launch, the Office of Inspector General released a report finding that the total cost of the HealthCare.gov website had reached $1.7 billion. On July 30, 2014, the Government Accountability Office released a non-partisan study that concluded the administration did not provide "effective planning or oversight practices" in developing the HealthCare.gov website.

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Answer 9

Health insurance cooperative

A health insurance cooperative is a cooperative entity that has the goal of providing health insurance and is also owned by the people that the organization insures. It is a form of mutual insurance.

In the debate over healthcare reform, healthcare cooperatives are posited as an alternative to both publicly funded healthcare and single-payer healthcare.

It has been proposed as part of the healthcare reform debate in the United States by the Barack Obama administration as a possible compromise with Blue Dog Democrats (as well as with Republicans) in the search for universal healthcare in the United States. As it is being proposed by President Obama and others, a future health insurance cooperative would not be government owned or run, but would instead receive an initial government investment and would then be operated as a non-profit organization.

While a health insurance co-op is not strictly run by the government, hence not making it a public entity, it has been described by Senator Max Baucus of Montana, who is also the chairman of the United States Senate Committee on Finance as "tough enough to keep insurance companies’ feet to the fire." He has proposed a bill that includes a health insurance cooperative instead of the public option.

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Answer 10

Foundation for Health Coverage Education

Foundation for Health Coverage Education

The Foundation for Health Coverage Education (FHCE) is a San Jose, California-based 501(c)3 non-profit organization that was founded in 2004 by Phil Lebherz. Lebherz established FHCE with the mission of simplify public and private health insurance eligibility information in order to help more people access coverage because one-third of the 49.9 million uninsured individuals in the U.S. are eligible for government-sponsored health coverage programs, but are not signed up.

FHCE works in conjunction with an Action Network of non-profit associations (American Cancer Society, American Heart Association, American Lung Association, American Diabetes Association, United Way-211 Call Centers, National Association of Health Underwriters, National Association of Insurance Commissioners) with outreach through national media outlets, such as CNN, the New York Times and the Wall Street Journal.James Pickens, Jr., star of the ABC television series Grey's Anatomy, spread the word about health coverage options for the uninsured by taping two public service announcements for FHCE’s “Coverage for All” campaign in 2008.

FHCE's website CoverageForAll.org has had over 4 million visitors since its creation in 2007. The non-profit's most popular online tool is its Health Coverage Eligibility Quiz. Users answer five basic household questions and are instantly presented with a personalized list of health coverage options, complete with program contact and cost information, sign-up checklists of important documents needed to enroll, and application links. Also available are downloadable resources detailing the public and private health coverage programs available in each state called the Health Coverage Options Matrix.

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