In English:

Health insurance comes in many forces. There are private insurances and government insurances.

Government health insurance usually means Medicare or Medicaid. Medicare is a federal program for retired persons typically over the age of 65 or people who are medically disabled. To get Medicare you have to have paid Medicare taxes which are typically withheld from paychecks. To qualify for Medicare as a medically disabled person you have to apply for disability through the Social Security department and this is a time consuming process that is not automatic. Medicaid is a state operated and partially federally funded program for the poor. Medicare and Medicaid both pay a percentage of a patient’s medical bill but the healthcare provider, by accepting Medicare or Medicaid must agree that the fee that these programs pay will be accepted as payment-in-full and balance billing is not allowed. The patient is responsible for 20% of the Medicare fee and usually a small co-payment is required of Medicaid patients. Providers who accept Medicare are being paid about half their usual fees when they accept payment from Medicare and are accepting about 15% of their usual fees when they accept Medicaid. For this reason, it is frequently more difficult for a Medicaid patient to find a provider willing to accept this very low fee schedule.

Most private health insurance is purchased by employers as part of a group policy. This allows the risk for the insurance company to be spread around. While health insurance can be purchased by an individual directly from the insurance company it is much more difficult to get and is more expensive. When buying insurance as an individual you have to prove to the insurance company that you are healthy and are unlikely to have medical bills that exceed the premiums you pay for the insurance. People with relatively moderate health problems typically cannot get private health insurance outside of a group-policy through an employer even if they are willing to pay a high premium. Some states require insurers to sell insurance through a state mandated heath insurance pool to the so-called uninsurable patients at a cost of typically $1,000 to $1,500 per month. The insurance companies in many cases will lose money on these policies but must offer these deals if they are to be allowed to sell insurance in a state.

Some employers will offer a choice of health insurance plans available to their employers and some employers will pay the entire premium for the individual but very few will pay for family coverage. Fees for family coverage can be paid by the employee, however. Employers that offer a choice of insurance plans will sometimes pay for the cheapest coverage and allow the employee to pay extra for better coverage. Managed care plans such as HMO’s (Health Maintenance Organizations) or PPO’s (Preferred Provider Organizations) try to save the insurer money by using various methods to control costs such as requiring the customer/patient to see a primary care provider prior to going to see a specialist and they may require pre-approval for some procedures or medicines to be used.

Some insurers will cover some or all of the cost of prescription medicines while others will not.

You should read policy and benefit manuals carefully to see which insurance plan is best for you and your particular conditions and medication needs.

Don Elton, MD

Tags: salud, seguro