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The term health insurance is generally used to describe a form of insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through government-sponsored social insurance programs, purchased on a group basis (e.g., by a firm to cover its employees) or purchased by individual consumers. In each case, the groups or individuals covered pay premiums or taxes in order to help protect themselves from high or unexpected healthcare expenses. Similar benefits paying for medical expenses may also be provided through social welfare programs funded by the government rather than the beneficiaries. Image File history File links Mergefrom. ... It has been suggested that this article or section be merged into Health insurance. ... Image File history File links Gnome-globe. ... Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of a contingent loss. ... This page is a candidate for speedy deletion. ... Long-term care insurance, an insurance product sold in the United States, helps provide for the cost of long-term care beyond a predetermined period. ... For specific national programs, see Social Security (United States), National insurance (UK), Social Security (Sweden) Social security refers to a variety of government programs providing for social welfare and social protection and the alleviation of poverty among senior citizens and the disabled. ...

Health insurance works by estimating the overall risk of healthcare expenses and developing a routine finance structure (such as a monthly premium, or annual tax) that will ensure that money is available to pay for the healthcare benefits specified in the insurance agreement. The healthcare benefit is administered by a central organization, which is most often either a government agency, or a private or not-for-profit entity operating a health plan. ^[1] It has been suggested that this article or section be merged into Health insurance. ...

Market-based health care systems such as that in the United States rely heavily on private and not-for-profit health insurance. In the U.S., according to the Census Bureau, some 60% of the population receives health insurance coverage through employer-sponsored plans. Government programs cover another 27% of the population, and about 9% of the population purchases insurance directly (there is some overlap in these figures). A market economy is a term used to describe an economy where economic decisions, such as pricing of goods and services, are made in a decentralized manner by the economys participants and manifested by trade. ... This article or section does not adequately cite its references or sources. ...

History and evolution

The concept of health insurance was proposed in 1694 by Hugh the Elder Chamberlen from the Peter Chamberlen family. In the late 19th century, "accident insurance" began to be available, which operated much like modern disability insurance.^[2]. This payment model continued until the start of the 20th century in some jurisdictions (like California), where all laws regulating health insurance actually referred to disability insurance.^[3] Patients were expected to pay all other health care costs out of their own pockets, under what is known as the fee-for-service business model. During the middle to late 20th century, traditional disability insurance evolved into modern health insurance programs. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and also most prescription drugs, but this was not always the case. Obstetrical Forceps, by Smellie (1792) Peter Chamberlen was the name of two brothers, the sons of William Chamberlen (about 1540 - 1596), a Huguenot surgeon who fled from Paris to England in 1576. ... Fee-for-service is health care coverage in which doctors and other health care providers receive a fee for each service such as an office visit, test, procedure, or other health care service[1]. Fee-for-service health insurance plans typically allow patients to obtain care from doctors or hospitals...

How it works

A Health insurance policy is a contract between an insurance company and an individual. The contract can be renewable annually or monthly. The type and amount of health care costs that will be covered by the health plan are specified in advance, in the member contract or Evidence of Coverage booklet. The individual policy-holder's payment obligations may take several forms^[4]: Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of a contingent loss. ...

• Premium: The amount the policy-holder pays to the health plan each month to purchase health coverage.
• Deductible: The amount that the policy-holder must pay out-of-pocket before the health plan pays its share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health plan. It may take several doctor's visits or prescription refills before the policy-holder reaches the deductible and the health plan starts to pay for care.
• Copayment: The amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service. For example, a policy-holder might pay a $45 copayment for a doctor's visit, or to obtain a prescription. A copayment must be paid each time a particular service is obtained.
• Coinsurance: Instead of paying a fixed amount up front (a copayment), the policy-holder must pay a percentage of the total cost. For example, the member might have to pay 20% of the cost of a surgery, while the health plan pays the other 80%. Because there is no upper limit on coinsurance, the policy-holder can end up owing very little, or a significant amount, depending on the actual costs of the services they obtain.
• Exclusions: Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket.
• Coverage limits: Some health plans only pay for health care up to a certain dollar amount. The policy-holder may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some plans have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining costs.
• Out-of-pocket maximums: Similar to coverage limits, except that in this case, the member's payment obligation ends when they reach the out-of-pocket maximum, and the health plan pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.

Prescription drug plans are a form of insurance offered through many employer benefit plans in the U.S., where the patient pays a copayment and the prescription drug insurance pays the rest.^{[citation needed]}

Some health care providers will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn't pay, as the insurance company pays according to "reasonable" or "customary" charges, which may be less than the provider's usual fee.^{[citation needed]}

Health insurance companies also often have a network of providers who agree to accept the reasonable and customary fee and waive the remainder.^{[citation needed]} It will generally cost the patient less to use an in-network provider.^{[citation needed]}

Inherent problems with insurance

Insurance systems must typically deal with two inherent challenges: adverse selection, which affects any voluntary system, and ex-post moral hazard, which affects any insurance system in which a third party bears major responsibility for payment, whether that is an employer or the government.

Adverse selection

Insurance companies use the term "adverse selection" to describe the tendency for only those who will benefit from insurance to buy it. Specifically when talking about health insurance, unhealthy people are more likely to purchase health insurance because they anticipate large medical bills. On the other side, people who consider themselves to be reasonably healthy may decide that medical insurance is an unnecessary expense; if they see the doctor once a year and it costs $250, that's much better than making monthly insurance payments of $400 (example figures). Adverse selection or anti-selection is a term used in economics and insurance. ...

The fundamental concept of insurance is that it balances costs across a large, random sample of individuals (see risk pool). For instance, an insurance company has a pool of 1000 randomly selected subscribers, each paying $100 per month. One person becomes very ill while the others stay healthy, allowing the insurance company to use the money paid by the healthy people to pay for the treatment costs of the sick person. However, when the pool is self-selecting rather than random, as is the case with individuals seeking to purchase health insurance directly, adverse selection is a greater concern.^[5] Some individuals have extremely high medical expenses, in extreme cases totaling a half million dollars or more. These represent a relatively small percentage of the insured population, however. ^[6] Adverse selection could leave an insurance company with primarily sick subscribers and no way to balance out the cost of their medical expenses with a large number of healthy subscribers. Risk Pool is one of the forms of risk management mostly practiced by insurance companies. ...

Because of adverse selection, insurance companies employ medical underwriting, using a patient's medical history to screen out those whose pre-existing medical conditions pose too great a risk for the risk pool. Before buying health insurance, a person typically fills out a comprehensive medical history form that asks whether the person smokes, how much the person weighs, whether the person has been treated for any of a long list of diseases and so on. In general, those who present a large financial burdens are denied coverage or charged high premiums to compensate.^[7] One large U.S. industry survey found that roughly 13 percent of applicants for comprehensive, individually purchased health insurance who went through the medical underwriting in 2004 were denied coverage. Declination rates increased significantly with age, rising from 5 percent for individuals 18 and under to just under a third for individuals aged 60 to 64.^[8] Among those who were offered coverage, the study found that 76% received offers at standard premium rates, and 22% were offered higher rates.^[9] On the other side, applicants can get discounts if they do not smoke and are healthy.^[10] Medical underwriting is an insurance term referring to the use of medical or health status information in the evaluation of an applicant for coverage (typically for life or health insurance). ...

Starting in 1976, some states started providing guaranteed-issuance risk pools, which enable individuals who are medically uninsurable through private health insurance to purchase a state-sponsored health insurance plan, usually at higher cost. Minnesota was the first to offer such a plan; 34 states now offer them. Plans vary greatly from state to state, both in their costs and benefits to consumers and to their methods of funding and operations. They serve a very small portion of the uninsurable market — about 182,000 people in the U.S. as of 2004,^[11] but in best cases allow people with pre-existing conditions such as cancer, diabetes, heart disease or other chronic illnesses to be able to switch jobs or seek self-employment without fear of being without health care benefits.^[12] Efforts to pass a national pool have as yet been unsuccessful, but some federal tax money has been awarded to states to innovate and improve their plans.

Moral hazard

Main article: Moral hazard

Moral hazard occurs when an insurer and a consumer enter into a contract under symmetric information, but one party takes action, not taken into account in the contract, which changes the value of the insurance. A common example of moral hazard is third-party payment — when the parties involved in making a decision are not responsible for bearing costs arising from the decision. An example is where doctors and insured patients agree to extra tests which may or may not be necessary. Doctors benefit by avoiding possible malpractice suits, and patients benefit by gaining increased certainty of their medical condition. The cost of these extra tests is borne by the insurance company, which may have had little say in the decision. Co-payments, deductibles, and less generous insurance for services with more elastic demand attempt to combat moral hazard, as they hold the consumer responsible. Moral hazard refers to the prospect that a party insulated from risk (such as through insurance) will not fully account for the negative consequences of the risk when deciding to act. ...

Other factors affecting insurance prices

A recent study by PriceWaterhouseCoopers examining the drivers of rising health care costs in the U.S. pointed to increased utilization created by increased consumer demand, new treatments, and more intensive diagnostic testing, as the most significant driver.^[13] People in developed countries are living longer. The population of those countries is aging, and a larger group of senior citizens requires more intensive medical care than a young healthier population. Advances in medicine and medical technology can also increase the cost of medical treatment. Other factors that increase utilization and therefore insurance prices are lifestyle-related: increases in obesity caused by insufficient exercise and unhealthy food choices; excessive alcohol use, smoking, and use of street drugs. Other factors noted by the PWC study included the movement to broader-access plans, higher-priced technologies, and cost-shifting from Medicaid and the uninsured to private payers.^[13] The term Exercise can refer to: Physical exercise such as running or strength training Exercise (options), the financial term for enacting and terminating a contract Category: ... Cheetos The Luther Burger, a bacon cheeseburger which employs a glazed donut in place of each bun. ... This article does not cite any references or sources. ... The cigarette is the most common method of smoking tobacco. ... Hard and soft drugs are loose categories of psychoactive drugs. ...

Health insurance in the United States

Main article: Health care in the United States

According to the United States Census Bureau, approximately 84% of Americans have health insurance. Some 60% obtain health insurance through an employer, about 9% purchase it directly, and various government agencies provide coverage to about 27% of Americans (there is some overlap in these figures).^[14] In 2006, there were 47 million people in the U.S. (16 percent of the population) who were without health insurance for at least part of that year.^[14] About 37% of the uninsured live in households with an income over $50,000.^[14] Health insurers have a significant economic impact as employers - in 2004 they directly employed almost 470,000 people at an average salary of $61,409.^[15] Health care in the United States is provided by many separate legal entities. ... The United States Census Bureau (officially Bureau of the Census as defined in Title ) is a part of the United States Department of Commerce. ...

Public: Medicare

Main article: Medicare (United States)

In the United States, government-funded Medicare programs help to insure the elderly and end stage renal disease patients. Some health care economists (Uwe Reinhardt of Princeton and Stuart Butler among others) assert that (the third party payment feature) these programs have had the unintended consequence of distorting the price of medical procedures. As a result, the Health Care Financing Administration has set up a list of procedures and corresponding prices under the Resource-Based Relative Value Scale. President Johnson signing the Medicare amendment. ... Kidneys viewed from behind with spine removed The kidneys are bean-shaped excretory organs in vertebrates. ... Princeton University is a private coeducational research university located in Princeton, New Jersey. ... Resource-Based Relative Value Scale (RBRVS) is a schema used to determine how much money medical providers should be paid. ...

Starting in 2006, Medicare Part D provides a program for the elderly to buy insurance for the purchase of prescription drugs.

Public: Medicare Advantage

Medicare Advantage plans expand the health care options for Medicare beneficiaries. The option for Medicare Advantage plans is a result of the Balanced Budget Act of 1997, with the intent to better control the rapid growth in Medicare spending, as well as to provide Medicare beneficiaries more choices. President Johnson signing the Medicare amendment. ... The Balanced Budget Act of 1997, Pub. ...

Public: Medicaid

Main article: Medicaid

While Medicaid was instituted for the very poor, beginning in 1972, the number of individuals in the United States who lacked any form of health insurance for any period during the year increased every year with the exceptions of the years 1999 and 2000.^{[citation needed]} It has been reported that the number of physicians accepting Medicaid has decreased in recent years due to relatively high administrative costs and low reimbursements. ^[16] Medicaid is the US health insurance program for individuals and families with low incomes and resources. ...

Private: employer-sponsored

Health insurance paid for by business entities generally on behalf of their employees and other immediate stakeholders. Broadly classified as "Traditional/Indemnity" and "Managed/Preferred Provider." Most private health coverage in the U.S. is employment based, and the employer typically makes a substantial contribution towards the cost of coverage.^[17]

Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation.^[18]

According to the Centers for Medicare and Medicaid Services, nearly 100% of large firms offer health insurance to their employees.^[19] Although much more likely to offer retiree health benefits than small firms, the percentage of large firms offering these benefits fell from 66% in 1988 to 34% in 2002.^[20]

Small employer group coverage

According to a 2007 study, about 59% of employers at small firms (3-199 workers) in the U.S. provide employee health insurance, compared to 99% of large employers. The percentage of small firms offering coverage has been dropping steadily since 1999. The study notes that cost remains the main reason cited by small firms who do not offer health benefits.^[21]

The types of coverage available to small employers are similar to those offered by large firms, but small businesses do not have the same options for financing their benefit plans. In particular, self-insuring the benefits (see Self-funded health care) is not a practical option for most small employers.^[22] Self-funded health care is an arrangement under which an employer helps finance the health care costs of its employees, taking on some of the risk of loss. ...

States regulate small group premium rates, typically by placing limits on the premium variation allowable between groups (rate bands). Insurers price to recover their costs over their entire book of small group business while abiding by state rating rules.^[23] Over time, the effect of initial underwriting "wears off" as the cost of a group regresses towards the mean — the average health status of the group eventually moves towards that of an average group.^[24] The process used to price small group coverage changes when a state enacts small group reform laws.^[25]

Insurance brokers play a significant role in helping small employers find health insurance, particularly in more competitive markets. Average small group commissions range from 2 percent to 8 percent of premiums. Brokers provide services beyond insurance sales, such as assisting with employee enrollment and helping to resolve benefits issues.^[26] An insurance broker sources (brokes) contracts of insurance on behalf of their customers. ...

The shift to managed care in the U.S.

Through the 1990s, managed care grew from about 25% of U.S. employees with employer-sponsored coverage to the vast majority. Managed care is a concept in U.S. health care. ... For other uses of terms redirecting here, see US (disambiguation), USA (disambiguation), and United States (disambiguation) Motto In God We Trust(since 1956) (From Many, One; Latin, traditional) Anthem The Star-Spangled Banner Capital Washington, D.C. Largest city New York City National language English (de facto)1 Demonym American... Employment is a contract between two parties, one being the employer and the other being the employee. ...

^[27] Managed care is a concept in U.S. health care. ... For other uses of terms redirecting here, see US (disambiguation), USA (disambiguation), and United States (disambiguation) Motto In God We Trust(since 1956) (From Many, One; Latin, traditional) Anthem The Star-Spangled Banner Capital Washington, D.C. Largest city New York City National language English (de facto)1 Demonym American... This article does not cite any references or sources. ... In health insurance, a preferred provider organization (or PPO, sometimes referred to as a participating provider organization) is a managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to... Managed care is a concept in U.S. health care. ... A High Deductible Health Plan (HDHP) is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. ...

Private: individually purchased

Policies of health insurance obtained by individuals not otherwise covered under policies or programs elsewhere classified. Generally major medical, short term medical, and student policies. According to the U.S. Census Bureau, about 9% of Americans are covered under health insurance purchased directly.^[14] The range of products available is similar to those provided through employers. Average premiums are generally somewhat lower than those for employer-sponsored coverage, but vary by age. Deductibles and other cost-sharing are also higher, on average, and the individual consumer pays the entire premium without benefit of an employer contribution.^[28]

Research confirms that consumers in the individual health insurance market are sensitive to price.^[29] Estimates of the demand elasticity in this market vary, but generally fall in the range of -0.3 to -0.1. It appears that price sensitivity varies among population subgroups, and is generally higher for younger individuals and lower income individuals.^[30]

Many states allow medical underwriting of applicants for individually purchased health insurance by insurance companies. A number of proposals have been advanced to limit the effect of underwriting on consumers and improve access to coverage. Each has its own advantages and limitations. ^[31] Medical underwriting is an insurance term referring to the use of medical or health status information in the evaluation of an applicant for coverage (typically for life or health insurance). ...

Private: Types in the U.S.

Traditional indemnity or fee-for-service

Commercial insurance companies began offering accident and sickness insurance (disability insurance) as early as the mid-1800s.^[32][33] Hospital and medical expense policies were introduced during the first half of the 20th century. The first group medical plan was purchased from The Equitable Life Assurance Society of the United States by the General Tire & Rubber Company in 1934.^[33]

Early hospital and medical plans offered by insurance companies paid either a fixed amount for specific diseases or medical procedures (schedule benefits) or paid a percentage of the provider's fee. The relationship between the patient and the medical provider was not changed. The patient received medical care and was responsible for paying the provider. If the service was covered by the policy, the insurance company was responsible for reimbursing or indemnifying the patient based on the provisions of the insurance contract ("reimbursement benefits"). Health insurance plans that are not based on a network of contracted providers, or that base payments on a percentage of provider charges, are still described as indemnity or fee-for-service plans.^[33][33] This concept became popular among hospitals during the depression, when they were facing declining revenues. The Baylor plan was a forerunner of later Blue Cross plans. Physician associations began offering pre-paid surgical/medical benefits in the late 1930s (Blue Shield plans). Blue Cross and Blue Shield plans were non-profit organizations sponsored by local hospitals (Blue Cross) or physician groups (Blue Shield). As originally structured, Blue Cross and Blue Shield plans provided benefits in the form of services rendered by participating hospitals and physicians ("service benefits") rather than reimbursements or payments to the policyholder.^[33][34] Look up Indemnity in Wiktionary, the free dictionary. ... Look up Indemnity in Wiktionary, the free dictionary. ... Fee-for-service is health care coverage in which doctors and other health care providers receive a fee for each service such as an office visit, test, procedure, or other health care service[1]. Fee-for-service health insurance plans typically allow patients to obtain care from doctors or hospitals... It has been suggested that Blue Shield of California be merged into this article or section. ... It has been suggested that Blue Shield of California be merged into this article or section. ...

Health Maintenance Organizations

Main article: Health Maintenance Organization

Henry J. Kaiser organized hospitals and clinics to provide pre-paid health benefits to his shipyard workers during World War II. This became the basis for the Health maintenance organization|health maintenance organization (HMO) Kaiser Permanente. The development of HMOs was encouraged by the passage of the Health Maintenance Organization Act of 1973. Benefits are provided through a network of providers. Providers may be employees of the HMO ("staff model"), employees of a provider group that has contracted with the HMO ("group model"), or members of an independent practice association ("IPA model"). HMOs may also use a combination of these approaches ("network model").^[33][34] This article does not cite any references or sources. ... Kaiser Permanente is an integrated managed care organization, based in Oakland, California, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney R. Garfield. ... The Health Maintenance Organization Act of 1973, also known as the HMO Act of 1973, is a law passed by the Congress of the United States that resulted from discussions Paul Ellwood had with what is today the Department of Health and Human Services. ...

Blurring lines

Over time, the operations of many Blue Cross and Blue Shield operations have become more similar to those of commercial health insurance companies (although many Blue Cross and Blue Shield plans do continue to serve as insurers of last resort).^{[citation needed]} Similarly, the benefits offered by Blues plans, commercial insurers, and HMOs are converging in many respects due to market pressures. One example is the convergence of preferred provider organization (PPO) plans offered by Blues and commercial insurers and the point of service plans offered by HMOs. Historically, commercial insurers, Blue Cross and Blue Shield plans, and HMOs might be subject to different regulatory oversight in a state (e.g., the Department of Insurance for insurance companies, versus the Department of Health for HMOs). Today, it is common for commercial insurance companies to have HMOs as subsidiaries, and for HMOs to have insurers as subsidiaries (the state license for an HMO is typically different from that for an insurance company).^[33][35][34] In health insurance, a preferred provider organization (or PPO, sometimes referred to as a participating provider organization) is a managed care organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to... A point of service plan, or POS plan, is a type of managed care health insurance system. ...

Historically, HMOs tended to use the term "health plan", while commercial insurance companies used the term "health insurance". The blurring of distinctions between the different types of health care coverage can be seen in the history of the industry's trade associations. The two primary HMO trade associations were the Group Health Association of America and the American Managed Care and Review Association. After merging, they were known as American Association of Health Plans (AAHP). The primary trade association for commercial health insurers was the Health Insurance Association of America (HIAA). These two have now merged, and are known as America’s Health Insurance Plans (AHIP). It has been suggested that this article or section be merged into Health insurance. ... This article is considered orphaned, since there are very few or no other articles that link to this one. ...

Long-term care insurance

Long-term care (LTC) insurance is growing in popularity in the U.S. Premiums have remained relatively stable in recent years. However, the coverage is quite expensive, especially when consumers wait until retirement age to purchase it. The average age of new purchasers was 61 in 2005, and has been dropping.^[36]

New types of medical plans in the U.S.

One approach to addressing increasing premiums, dubbed "consumer driven health care," received a boost in 2003, when President George W. Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act. The law created tax-deductible Health Savings Accounts (HSAs). An HSA is a private bank account which is un-taxed and only penalized if spent on non-medical items or services. It must be paired with a high-deductible insurance plan. HSAs enable mostly healthy people to pay less for insurance and bank money for their own health care expenses.^[37] HSAs are one form of tax-preferenced health care spending account. Others include Archer Medical Savings Accounts (MSAs), which have been superseded by the new HSAs (although existing MSAs are grandfathered), Flexible Spending Arrangements (FSAs) and Health Reimbursement Accounts (HRAs). FSAs and HRAs are typically used as part of an employee-benefit plan.^[38] This article or section is in need of attention from an expert on the subject. ... The Medicare Prescription Drug, Improvement, and Modernization Act (Public Law No. ... The Health savings account (HSA) is the new name for the Medical savings account (MSA) plans in the United States. ...

Limited Medical Benefit Plans pay for routine care and do not pay for catastrophic care. As such, they do not provide equivalent financial security to a major medical plan. Annual benefit limits can be as low as $2,000. Lifetime maximums can be very low as well.

Health insurance in Canada

Most health insurance in Canada is administered by each province, under the national law that requires all people to have free access to basic health services. Collectively, the public provincial health insurance systems in Canada are frequently referred to as Medicare. Private health insurance in Canada is allowed only for services that the public health plans do not cover; for example, semi-private or private rooms in hospitals and prescription drug plans. Canadians also must use private insurance for elective medical services such as Lasik surgery, plastic surgery such as liposuction, and other non-basic medical procedures. Private health insurance cannot cover physician fees which are covered by Medicare. Some 65% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers.^[39] Private-sector services not paid for by the government account for nearly 30 percent of total health care spending.^[40] In 2005, the Supreme Court of Quebec ruled, in Chaoulli v. Quebec, that the prohibition on insurance for health care already insured by the state constitutes an infringement of the right to life and security. It is yet to be seen if this ruling will change the overall delivery of health insurance across Canada. The term medicare (in lowercase) (French: assurance maladie) is the unofficial name for Canadas universal public health insurance system. ... Holding Section 15 of the Health Insurance Act and section 11 of the Hospital Insurance Act, which outlaw private medical insurance, violate the right to personal inviolability as guaranteed by the Quebec Charter of Human Rights and Freedoms Court membership Chief Justice: Beverley McLachlin Puisne Justices: John C. Major, Michel...

Health insurance in Australia

The public health system is called Medicare. It ensures free universal access to hospital treatment and subsidised out-of-hospital medical treatment. It is funded by a 1.5% tax levy. Medicare is Australias publicly-funded universal health care system, operated by the government authority Medicare Australia. ...

The private health system is funded by a number of private health insurance organisations. The largest of these is Medibank Private, which is government-owned, but operates as a government business enterprise under the same regulatory regime as all other registered private health funds. The conservative Howard government had announced that Medibank will be privatised in 2008 if it won the 2007 election. The electorate however voted into office the opposing Australian Labor Party under Kevin Rudd which had already pledged that it would remain in government ownership if the party was elected into office. Medibank Private is an Australian Government owned private health insurer, established under the Fraser government in 1976 through the Health Insurance Commission. ... A government corporation, government-owned corporation or government business enterprise is a legal entity created by a government to exercise some of the powers of the government. ... John Winston Howard (born 26 July 1939) is an Australian politician and the 25th Prime Minister of Australia. ... The 2007 election for the federal Parliament of Australia, in which 13. ... ALP redirects here. ... Kevin Michael Rudd (born 21 September 1957), is the leader of the federal Australian Labor Party and Leader of the Opposition in the Australian Parliament. ...

Some private health insurers are 'for profit' enterprises, and some are non-profit organizations such as HCF Health Insurance. Some have membership restricted to particular groups, but the majority have open membership. A non-profit organization (abbreviated NPO, or non-profit or not-for-profit) is an organization whose primary objective is to support an issue or matter of private interest or public concern for non-commercial purposes, without concern for monetary profit. ... HCF was formed in 1932 to provide health insurance cover to Australians. ...

Most aspects of private health insurance in Australia are regulated by the Private Health Insurance Act 2007.

The private health system in Australia operates on a "community rating" basis, whereby premiums do not vary solely because of a person's previous medical history, current state of health, or (generally speaking) their age (but see Lifetime Health Cover below). Balancing this are waiting periods, in particular for pre-existing conditions (usually referred to within the industry as PEA, which stands for "pre-existing ailment"). Funds are entitled to impose a waiting period of up to 12 months on benefits for any medical condition the signs and symptoms of which existed during the six months ending on the day the person first took out insurance. They are also entitled to impose a 12-month waiting period for benefits for treatment relating to an obstetric condition, and a 2-month waiting period for all other benefits when a person first takes out private insurance. Funds have the discretion to reduce or remove such waiting periods in individual cases. They are also free not to impose them to begin with, but this would place such a fund at risk of "adverse selection", attracting a disproportionate number of members from other funds, or from the pool of intending members who might otherwise have joined other funds. It would also attract people with existing medical conditions, who might not otherwise have taken out insurance at all because of the denial of benefits for 12 months due to the PEA Rule. The benefits paid out for these conditions would create pressure on premiums for all the fund's members, causing some to drop their membership, which would lead to further rises, and a vicious cycle would ensue.

There are a number of other matters about which funds are not permitted to discriminate between members in terms of premiums, benefits or membership - these include racial origin, religion, sex, sexual orientation, nature of employment, and leisure activities. Premiums for a fund's product that is sold in more than one state can vary from state to state, but not within the same state.

The Australian government has introduced a number of incentives to encourage adults to take out private hospital insurance. These include:

• Lifetime Health Cover: If a person has not taken out private hospital cover by the 1st July after their 30th birthday, then when (and if) they do so after this time, their premiums must include a loading of 2% per annum. Thus, a person taking out private cover for the first time at age 40 will pay a 10 per cent loading. The loading continues for 10 years. The loading applies only to premiums for hospital cover, not to ancillary (extras) cover.

• Medicare Levy Surcharge: People whose taxable income is greater than a specified amount (currently $50,000 for singles and $100,000 for families) and who do not have an adequate level of private hospital cover must pay a 1% surcharge on top of the standard 1.5% Medicare Levy. The rationale is that if the people in this income group are forced to pay more money one way or another, most would choose to purchase hospital insurance with it, with the possibility of a benefit in the event that they need private hospital treatment - rather than pay it in the form of extra tax as well as having to meet their own private hospital costs.

• Private Health Insurance Rebate: The government subsidises the premiums for all private health insurance cover, including hospital and ancillary (extras), by 30%, 35% or 40%.

Common complaints of private insurance

This section is missing citations or needs footnotes. Using inline citations helps guard against copyright violations and factual inaccuracies.

Some common complaints about private health insurance include: Image File history File links Emblem-important. ...

1. Insurance companies usually only re-price their coverage annually.^{[citation needed]} This means if one becomes ill, and is covered by a health insurance policy, and that illness will continue and be subject to a re-priced policy that person may find that their insurance premiums have increased to an amount they might not be able to afford. However, some states have rules and regulations which can limit price increases on certain types of health insurance coverage.
2. If insurance companies try to charge different people different amounts based on their own personal health, people may feel they are unfairly treated.^{[citation needed]} Exceptions to this differential in pricing can be found when an individual (and their dependents) become insured under a pre-existing pool of insureds such as a group of employees insured through their employer. In that instance, the underwriter assesses the financial risk based upon the entire group (sometimes referred to as a 'risk pool'). In these situations, a person with little or no medical expenses in their recent history will pay the same premium cost (and be subject to the same co-pays and deductibles) as someone who has had a large amount of medical expenses in their recent history.
3. When a claim is made, particularly for a sizable amount, insureds may feel as though the insurance company is using paperwork and bureaucracy to attempt to avoid payment of the claim or, at a minimum, greatly delay it.^{[citation needed]} One large industry survey suggests that claim processing times improved between 2002 and 2006. More claims are being submitted electronically; however, 29 percent of claims were not received by the insurer until more than a month after the date on which medical care was provided. The percentage of claims being adjudicated on an automated basis is also increasing. 14 percent of claims are "pended" by the insurer while additional information is requested or the information on the claim is verified. On average, pended claims are delayed by 9 days. Over 95 percent of the remaining "clean" claims are processed within 30 days; 57 percent are processed within one week.^[41]
4. Health insurance is often only widely available at a reasonable cost through an employer-sponsored group plan and online for individuals who are healthy.^{[citation needed]}
5. In the United States, there are tax advantages to Employer-provided health insurance, whereas individuals must pay tax on income used to fund their own health insurance, although a small number of pre-tax health plans exist.^{[citation needed]}
6. Experimental treatments are generally not covered.^{[citation needed]} This practice is especially criticized by those who have already tried, and not benefited from, all "standard" medical treatments for their condition.^{[citation needed]}
7. The Health Maintenance Organization (HMO) type of health insurance plan has been criticized for excessive cost-cutting policies in its attempt to offer lower premiums to consumers.^{[citation needed]}
8. As the health care recipient is not directly involved in payment of health care services and products, they are less likely to scrutinize or negotiate the costs of the health care received.^{[citation needed]} The health care company has popular and unpopular ways of controlling this market force.^{[citation needed]}
9. Some health care providers end up with different sets of rates for the same procedure. One for people with insurance and another for those without.^{[citation needed]}
10. Insurance Companies can influence the type or amount of treatment that the insured receives by setting limits on the number of visits, types of treatment, etc., it will cover.

This article does not cite any references or sources. ...

Notes and references

• Navigating your health benefits for dummies. Charles M Cutler MD Tracey A Baker CFP (c)2006 ISBN-13:978-0-470-08354-3

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See also

• COBRA
• Injury cover
• Economic capital
• Government ownership
• Health economics
• Health maintenance organization
• Healthcare reform
• Health Insurance Portability and Accountability Act
• Self-funded health care
• List of insurance topics
• Physicians for a National Health Program
• Public health
• RAND Health Insurance Experiment
• Sicko (film)
• Social security
• Social welfare
• America’s Health Insurance Plans

The Act allows both workers and their immediate family members who had been covered by a health care plan to maintain their coverage if a qualifying event causes them to lose coverage. ... Injury cover may refer to the act of receiving or claiming compensation for work related injuries. ... Capital has a number of related meanings in economics, finance and accounting. ... Public ownership (also called government ownership or state ownership) is government ownership of any asset, industry, or corporation at any level, national, regional or local (municipal). ... Health economics is a branch of economics concerned with issues related to scarcity in the allocation of health and health care. ... This article does not cite any references or sources. ... Healthcare reform is a general rubric used for discussing major policy changes--for the most part, governmental policy changes--to any existing healthcare system in a given place. ... The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996. ... Self-funded health care is an arrangement under which an employer helps finance the health care costs of its employees, taking on some of the risk of loss. ... Topics in finance include: // Finance an overview Arbitrage Capital (economics) Capital asset pricing model Cash flow Cash flow matching Debt Default Consumer debt Debt consolidation Debt settlement Credit counseling Bankruptcy Debt diet Debt-snowball method Discounted cash flow Financial capital Funding Financial modeling Entrepreneur Entrepreneurship Fixed income analysis Gap financing... To meet Wikipedias quality standards, this article or section may require cleanup. ... Public health is the study and practice of addressing threats to the health of a community. ... The RAND Health Insurance Experiment remains one of the most rigorous and comprehensive studies of health care cost, utilitzation and outcome. ... For other uses, see Sicko (disambiguation). ... Social security primarily refers to social welfare service concerned with social protection, or protection against socially recognized conditions, including poverty, old age, disability, unemployment and others. ... ... This article is considered orphaned, since there are very few or no other articles that link to this one. ...

External links (United States)

• National Association of State Comprehensive Health Insurance Plans (NASCHIP): http://www.naschip.org/
• National Association of Health Underwriters (NAHU) http://www.nahu.org
• Kaiser Family Foundation: http://www.kff.org/insurance/7672/index.cfm
• Center for Studying Health System Change: http://www.hschange.com/
• AHIP Center for Policy and Research: http://www.ahipresearch.org/
• U.S. Census Bureau - Health Insurance Statistics: http://www.census.gov/hhes/www/hlthins/hlthins.html
• National Health Expenditure Data (U.S.): http://www.cms.hhs.gov/NationalHealthExpendData/01_Overview.asp
• National Center for Health Statistics: http://www.cdc.gov/nchs/
• National Association of Insurance Commissioners: http://www.naic.org/
• Health Claim Appeals - A Guide to Resolving Health Insurance Disputes: http://www.healthclaimappeals.org/
• Centers for Medicare and Medicaid Services: http://www.cms.hhs.gov
• A History of Health Insurance Benefits from the Employee Benefits Research Institute (EBRI): http://www.ebri.org/publications/facts/index.cfm?fa=0302fact