Health insurance is a form of risk management that helps pay for medical and surgical expenses. It is generally offered by employers as part of a benefits package, and is available to individuals through private insurers as well as the government in the case of public plans such as Medicare. There are many different types of health insurance plans, and they can vary significantly in terms of what they cover and how it is accessed. Most plans have some type of managed care model, with a network of doctors and hospitals that have agreed to provide services at a reduced rate for plan members (or enrollees). These are called preferred provider organizations or networks. In most cases, a member will have to choose a primary care physician (PCP) who will then refer them to specialists within the network.
Most plans have a deductible and coinsurance, which are the amounts that you are responsible to pay out of pocket before the insurance starts to pay. Deductibles and coinsurance are typically listed on your insurance card. Most plans also have specific lists of covered medications, which are drugs the insurance company has approved to be paid for under the plan. This list is known as a formulary.
In addition, most plans offer a range of preventive health services at no cost to the member. This includes annual checkups, flu shots, certain vaccinations, and more. However, it is important to remember that just because something is “covered” doesn’t mean it is necessarily the best option for you. Many people have found that the best value comes from a combination of preventive care and more targeted treatment for conditions like heart disease or cancer.
A key function of healthcare is to help individuals get the right care at the right time, and that means helping them make smart decisions about their care. However, some health insurers are using their power to limit access to care in an effort to lower costs. This can include requiring prior authorization for some procedures and treatments, or requiring forms to be filled out in order to obtain coverage for experimental treatments.
This trend is troubling, as it limits the ability of physicians to determine what is in the best interests of their patients. It can also interfere with patients’ abilities to access the care that they need, and it may be harmful to their health. This is why it is important for everyone to be aware of how their health insurance works so that they can advocate on behalf of themselves and their loved ones. If you have any questions about your insurance, contact your health insurance provider or a consumer advocacy group for help.