language
You Won't Believe These Suez Canal Conspiracies
4 years ago
Showing posts with label insurance. Show all posts
Showing posts with label insurance. Show all posts
Monday, February 17, 2020
Tuesday, October 25, 2016
Saturday, August 20, 2016
Wednesday, October 7, 2009
Keith Obermann healthcare commentary
This was Keith's comment on healthcare this evening. Well worth review and I hope I put these in the correct order.
My opinion: Keith's presentation equals Sicko movie and this will be a topic at next meeting. Yes, we are still onboard with single-payer health care, HR676.
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My opinion: Keith's presentation equals Sicko movie and this will be a topic at next meeting. Yes, we are still onboard with single-payer health care, HR676.
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Visit msnbc.com for Breaking News, World News, and News about the Economy
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Visit msnbc.com for Breaking News, World News, and News about the Economy
Visit msnbc.com for Breaking News, World News, and News about the Economy
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Visit msnbc.com for Breaking News, World News, and News about the Economy
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Visit msnbc.com for Breaking News, World News, and News about the Economy
Tuesday, July 28, 2009
Fiore cartoon Dr Decline
This is a Fiore cartoon dealing with healthcare. About two minutes and worth watching:
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I posted this on another of our blogs, but some folks could not open the vid. It is copyrighted and I shall withdraw if objections made
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I posted this on another of our blogs, but some folks could not open the vid. It is copyrighted and I shall withdraw if objections made
Tuesday, May 26, 2009
Excellent Krugman comment on healthcare mess
Krugman is an excellent writer and brilliant thinker. These comments should be the talk of the town, but alas they are not.
----------------------------------------------------
May 11, 2009
Op-Ed Columnist
Harry, Louise and Barack
By PAUL KRUGMAN
Is this the end for Harry and Louise?
Harry and Louise were the fictional couple who appeared in advertisements run by the insurance industry in 1993, fretting about what would happen if “government bureaucrats” started making health care decisions. The ads helped kill the Clinton health care plan, and have stood, ever since, as a symbol of the ability of powerful special interests to block health care reform.
But on Saturday, excited administration officials called me to say that this time the medical-industrial complex (their term, not mine) is offering to be helpful.
Six major industry players — including America’s Health Insurance Plans (AHIP), a descendant of the lobbying group that spawned Harry and Louise — have sent a letter to President Obama sketching out a plan to control health care costs. What’s more, the letter implicitly endorses much of what administration officials have been saying about health economics.
Are there reasons to be suspicious about this gift? You bet — and I’ll get to that in a bit. But first things first: on the face of it, this is tremendously good news.
The signatories of the letter say that they’re developing proposals to help the administration achieve its goal of shaving 1.5 percentage points off the growth rate of health care spending. That may not sound like much, but it’s actually huge: achieving that goal would save $2 trillion over the next decade.
How are costs to be contained? There are few details, but the industry has clearly been reading Peter Orszag, the budget director.
In his previous job, as the director of the Congressional Budget Office, Mr. Orszag argued that America spends far too much on some types of health care with little or no medical benefit, even as it spends too little on other types of care, like prevention and treatment of chronic conditions. Putting these together, he concluded that “substantial opportunities exist to reduce costs without harming health over all.”
Sure enough, the health industry letter talks of “reducing over-use and under-use of health care by aligning quality and efficiency incentives.” It also picks up a related favorite Orszag theme, calling for “adherence to evidence-based best practices and therapies.” All in all, it’s just what the doctor, er, budget director ordered.
Before we start celebrating, however, we have to ask the obvious question. Is this gift a Trojan horse? After all, several of the organizations that sent that letter have in the past been major villains when it comes to health care policy.
I’ve already mentioned AHIP. There’s also the Pharmaceutical Research and Manufacturers of America (PhRMA), the lobbying group that helped push through the Medicare Modernization Act of 2003 — a bill that both prevented Medicare from bargaining over drug prices and locked in huge overpayments to private insurers. Indeed, one of the new letter’s signatories is former Representative Billy Tauzin, who shepherded that bill through Congress then immediately left public office to become PhRMA’s lavishly paid president.
The point is that there’s every reason to be cynical about these players’ motives. Remember that what the rest of us call health care costs, they call income.
What’s presumably going on here is that key interest groups have realized that health care reform is going to happen no matter what they do, and that aligning themselves with the Party of No will just deny them a seat at the table. (Republicans, after all, still denounce research into which medical procedures are effective and which are not as a dastardly plot to deprive Americans of their freedom to choose.)
I would strongly urge the Obama administration to hang tough in the bargaining ahead. In particular, AHIP will surely try to use the good will created by its stance on cost control to kill an important part of health reform: giving Americans the choice of buying into a public insurance plan as an alternative to private insurers. The administration should not give in on this point.
But let me not be too negative. The fact that the medical-industrial complex is trying to shape health care reform rather than block it is a tremendously good omen. It looks as if America may finally get what every other advanced country already has: a system that guarantees essential health care to all its citizens.
And serious cost control would change everything, not just for health care, but for America’s fiscal future. As Mr. Orszag has emphasized, rising health care costs are the main reason long-run budget projections look so grim. Slow the rate at which those costs rise, and the future will look far brighter.
I still won’t count my health care chickens until they’re hatched. But this is some of the best policy news I’ve heard in a long time.
----------------------------------------------------
May 11, 2009
Op-Ed Columnist
Harry, Louise and Barack
By PAUL KRUGMAN
Is this the end for Harry and Louise?
Harry and Louise were the fictional couple who appeared in advertisements run by the insurance industry in 1993, fretting about what would happen if “government bureaucrats” started making health care decisions. The ads helped kill the Clinton health care plan, and have stood, ever since, as a symbol of the ability of powerful special interests to block health care reform.
But on Saturday, excited administration officials called me to say that this time the medical-industrial complex (their term, not mine) is offering to be helpful.
Six major industry players — including America’s Health Insurance Plans (AHIP), a descendant of the lobbying group that spawned Harry and Louise — have sent a letter to President Obama sketching out a plan to control health care costs. What’s more, the letter implicitly endorses much of what administration officials have been saying about health economics.
Are there reasons to be suspicious about this gift? You bet — and I’ll get to that in a bit. But first things first: on the face of it, this is tremendously good news.
The signatories of the letter say that they’re developing proposals to help the administration achieve its goal of shaving 1.5 percentage points off the growth rate of health care spending. That may not sound like much, but it’s actually huge: achieving that goal would save $2 trillion over the next decade.
How are costs to be contained? There are few details, but the industry has clearly been reading Peter Orszag, the budget director.
In his previous job, as the director of the Congressional Budget Office, Mr. Orszag argued that America spends far too much on some types of health care with little or no medical benefit, even as it spends too little on other types of care, like prevention and treatment of chronic conditions. Putting these together, he concluded that “substantial opportunities exist to reduce costs without harming health over all.”
Sure enough, the health industry letter talks of “reducing over-use and under-use of health care by aligning quality and efficiency incentives.” It also picks up a related favorite Orszag theme, calling for “adherence to evidence-based best practices and therapies.” All in all, it’s just what the doctor, er, budget director ordered.
Before we start celebrating, however, we have to ask the obvious question. Is this gift a Trojan horse? After all, several of the organizations that sent that letter have in the past been major villains when it comes to health care policy.
I’ve already mentioned AHIP. There’s also the Pharmaceutical Research and Manufacturers of America (PhRMA), the lobbying group that helped push through the Medicare Modernization Act of 2003 — a bill that both prevented Medicare from bargaining over drug prices and locked in huge overpayments to private insurers. Indeed, one of the new letter’s signatories is former Representative Billy Tauzin, who shepherded that bill through Congress then immediately left public office to become PhRMA’s lavishly paid president.
The point is that there’s every reason to be cynical about these players’ motives. Remember that what the rest of us call health care costs, they call income.
What’s presumably going on here is that key interest groups have realized that health care reform is going to happen no matter what they do, and that aligning themselves with the Party of No will just deny them a seat at the table. (Republicans, after all, still denounce research into which medical procedures are effective and which are not as a dastardly plot to deprive Americans of their freedom to choose.)
I would strongly urge the Obama administration to hang tough in the bargaining ahead. In particular, AHIP will surely try to use the good will created by its stance on cost control to kill an important part of health reform: giving Americans the choice of buying into a public insurance plan as an alternative to private insurers. The administration should not give in on this point.
But let me not be too negative. The fact that the medical-industrial complex is trying to shape health care reform rather than block it is a tremendously good omen. It looks as if America may finally get what every other advanced country already has: a system that guarantees essential health care to all its citizens.
And serious cost control would change everything, not just for health care, but for America’s fiscal future. As Mr. Orszag has emphasized, rising health care costs are the main reason long-run budget projections look so grim. Slow the rate at which those costs rise, and the future will look far brighter.
I still won’t count my health care chickens until they’re hatched. But this is some of the best policy news I’ve heard in a long time.
The Influence Game healthcare
This is from Boston Globe and simular article in the Post Dispatch:
THE INFLUENCE GAME: Health lobbyist has great sway
Associated Press
If anyone could make or break President Barack Obama's health care agenda, it might be Karen Ignagni.
Erica Werner
May 24, 2009
THE INFLUENCE GAME: Health lobbyist has great sway
By Erica Werner, Associated Press Writer May 24, 2009
WASHINGTON --If anyone could make or break President Barack Obama's health care agenda, it might be Karen Ignagni.
The Democratic former union official and firefighter's daughter is also the unlikely face of the powerful health insurance industry as its top Washington lobbyist.
Ignagni is such a formidable advocate that when she went head to head with industry-bashing filmmaker Michael Moore on the Oprah Winfrey show, she emerged not only unscathed, but with Moore seconding some of her points.
Now, with the prospect of a congressional health care overhaul looming, Ignagni's role is more important than ever. It's a moment she's long prepared for.
Ignagni and her board at America's Health Insurance Plans foresaw three years ago that 2009 could be a year that health care would top the agenda, and they decided to craft a plan.
For months, Ignagni has been fleshing out their proposal bit by bit at congressional hearings, ensuring maximum attention.
The plan would achieve Obama's goal of universal health coverage through a regulated insurance market. Insurers would agree to significant concessions such as not charging more to people with pre-existing conditions. In return, they want to quash a government-run insurance plan that Obama supports, but that Ignagni fears would put private insurers out of business.
Although Congress may not embrace all her proposals, Ignagni can claim notable success in positioning her industry as an ally of health care change, not its enemy. That's a 180-degree turnaround from where the industry was during the health care wars of the Clinton years.
Not only are health insurers at the table, they're sometimes driving the debate, as with the White House announcement this month that the health industry would cut its own costs by $2 trillion to further Obama's cause. Ignagni was a key architect.
"She's gifted at anticipating what issues are likely to be," said George Halvorson, chairman of the Kaiser Foundation Health Plan and AHIP's immediate past board chairman. He credited Ignagni with orchestrating the board's preparation for the health care debate.
"The fact that we sat down and wrestled with all of the issues on underwriting and so forth was genius on her part," Halvorson said.
But as publicly constructive as the insurance industry's role has been so far, a giant question mark remains: What will Ignagni do if Congress does produce a bill she doesn't like? Will her group try to kill it, resurrecting "Harry and Louise"-style attack ads that proved so devastating during the Clinton years? That could doom Obama's health care goals.
Liberals fear AHIP is already preparing the wrecking ball. Ignagni refuses to say how they'll respond to an unfavorable bill.
"We're how many weeks away from seeing whatever is proposed? So no responsible person could answer a question like that," Ignagni, 55, said in an interview.
"The people who are working on this issue, even in areas where we have differences, are very thoughtful, have the right objectives, and we have a long history of working with them," she added. "So we're going to give them the courtesy of thoughtfully responding to what they propose."
Ignagni didn't work for the insurance group that produced the "Harry and Louise" commercials. Indeed the man most responsible for them, Chip Kahn, who's now at the Federation of American Hospitals, went up against Ignagni when their two insurance lobbies merged in 2003, and she beat him out for her current job. Kahn declined to comment for this story.
"Whatever AHIP pays her, it's not enough. She's unbelievably effective," said Princeton economist Uwe Reinhardt. "It's just amazing what she's achieved for them against all odds."
Ignagni's total compensation, according to AHIP's most recent filing from 2007, was $1.58 million, which includes $700,000 in base salary, $370,000 in deferred compensation and a bonus. Ignagni won't say how many hours a week she works. The number's so high it's embarrassing, she said.
Among successes cited by Reinhardt and others is helping persuade the Bush administration to develop private insurance plans within Medicare that are producing unexpectedly high payments for private insurers.
When Congress was considering expanding a children's health insurance program in 2007 by taking money from the private Medicare Advantage plans, Ignagni worked successfully to stop it.
Those private plans are being targeted again by Obama, who wants to squeeze them to pay for his health care agenda. Ignagni's industry group is organizing older people to defend the plans.
A front group called the Coalition for Medicare Choices has a Web site inviting older people to share their stories about Medicare Advantage. The fine print gives AHIP the right to use that information however it wants.
Ignagni's job isn't easy. AHIP's board consists of chief executives of top insurers and Ignagni has to bring them to consensus in order to make her moves. People who work with her say she does it by listening hard and being well-informed, respectful and prepared.
"She's always on her game and knows her substance," said Tom Scully, a former Medicare administrator. "Health insurance CEOs come and go, but Karen has been a constant."
------
On the Net:
America's Health Insurance Plans: http://www.ahip.org/
© Copyright
THE INFLUENCE GAME: Health lobbyist has great sway
Associated Press
If anyone could make or break President Barack Obama's health care agenda, it might be Karen Ignagni.
Erica Werner
May 24, 2009
THE INFLUENCE GAME: Health lobbyist has great sway
By Erica Werner, Associated Press Writer May 24, 2009
WASHINGTON --If anyone could make or break President Barack Obama's health care agenda, it might be Karen Ignagni.
The Democratic former union official and firefighter's daughter is also the unlikely face of the powerful health insurance industry as its top Washington lobbyist.
Ignagni is such a formidable advocate that when she went head to head with industry-bashing filmmaker Michael Moore on the Oprah Winfrey show, she emerged not only unscathed, but with Moore seconding some of her points.
Now, with the prospect of a congressional health care overhaul looming, Ignagni's role is more important than ever. It's a moment she's long prepared for.
Ignagni and her board at America's Health Insurance Plans foresaw three years ago that 2009 could be a year that health care would top the agenda, and they decided to craft a plan.
For months, Ignagni has been fleshing out their proposal bit by bit at congressional hearings, ensuring maximum attention.
The plan would achieve Obama's goal of universal health coverage through a regulated insurance market. Insurers would agree to significant concessions such as not charging more to people with pre-existing conditions. In return, they want to quash a government-run insurance plan that Obama supports, but that Ignagni fears would put private insurers out of business.
Although Congress may not embrace all her proposals, Ignagni can claim notable success in positioning her industry as an ally of health care change, not its enemy. That's a 180-degree turnaround from where the industry was during the health care wars of the Clinton years.
Not only are health insurers at the table, they're sometimes driving the debate, as with the White House announcement this month that the health industry would cut its own costs by $2 trillion to further Obama's cause. Ignagni was a key architect.
"She's gifted at anticipating what issues are likely to be," said George Halvorson, chairman of the Kaiser Foundation Health Plan and AHIP's immediate past board chairman. He credited Ignagni with orchestrating the board's preparation for the health care debate.
"The fact that we sat down and wrestled with all of the issues on underwriting and so forth was genius on her part," Halvorson said.
But as publicly constructive as the insurance industry's role has been so far, a giant question mark remains: What will Ignagni do if Congress does produce a bill she doesn't like? Will her group try to kill it, resurrecting "Harry and Louise"-style attack ads that proved so devastating during the Clinton years? That could doom Obama's health care goals.
Liberals fear AHIP is already preparing the wrecking ball. Ignagni refuses to say how they'll respond to an unfavorable bill.
"We're how many weeks away from seeing whatever is proposed? So no responsible person could answer a question like that," Ignagni, 55, said in an interview.
"The people who are working on this issue, even in areas where we have differences, are very thoughtful, have the right objectives, and we have a long history of working with them," she added. "So we're going to give them the courtesy of thoughtfully responding to what they propose."
Ignagni didn't work for the insurance group that produced the "Harry and Louise" commercials. Indeed the man most responsible for them, Chip Kahn, who's now at the Federation of American Hospitals, went up against Ignagni when their two insurance lobbies merged in 2003, and she beat him out for her current job. Kahn declined to comment for this story.
"Whatever AHIP pays her, it's not enough. She's unbelievably effective," said Princeton economist Uwe Reinhardt. "It's just amazing what she's achieved for them against all odds."
Ignagni's total compensation, according to AHIP's most recent filing from 2007, was $1.58 million, which includes $700,000 in base salary, $370,000 in deferred compensation and a bonus. Ignagni won't say how many hours a week she works. The number's so high it's embarrassing, she said.
Among successes cited by Reinhardt and others is helping persuade the Bush administration to develop private insurance plans within Medicare that are producing unexpectedly high payments for private insurers.
When Congress was considering expanding a children's health insurance program in 2007 by taking money from the private Medicare Advantage plans, Ignagni worked successfully to stop it.
Those private plans are being targeted again by Obama, who wants to squeeze them to pay for his health care agenda. Ignagni's industry group is organizing older people to defend the plans.
A front group called the Coalition for Medicare Choices has a Web site inviting older people to share their stories about Medicare Advantage. The fine print gives AHIP the right to use that information however it wants.
Ignagni's job isn't easy. AHIP's board consists of chief executives of top insurers and Ignagni has to bring them to consensus in order to make her moves. People who work with her say she does it by listening hard and being well-informed, respectful and prepared.
"She's always on her game and knows her substance," said Tom Scully, a former Medicare administrator. "Health insurance CEOs come and go, but Karen has been a constant."
------
On the Net:
America's Health Insurance Plans: http://www.ahip.org/
© Copyright
Thursday, May 21, 2009
Healthcare terms
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Hard to keep up with verbage in the healthcare debate. Some folks do not understand some of the terms and this is a brief and good list from: http://www.insurancecompanyrules.org/pages/glossary/
Note: in our contract and benefit books, some of these "terms" are loose and subject to the "companies" interpretation; something not to our benefit. With the recient retiree loss in courts, companies and insurance folks have the upper hand in dealing with our folks (Rexam vs USW). This is not good for the average worker or retiree for the law protects companies and insurance companies against lawsuits.
Note: details of some of these lawsuits are in the files of our blog at: http://groups.yahoo.com/group/slsoarpac/files/
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-A-
Affiliation Period. The amount of time a new plan member must wait before being eligible for health care coverage, imposed by the health plan and not an employer. This waiting period cannot last longer than three months.
-B-
Balance Billing. When doctors and hospitals charge patients the difference between their fee and the amount their insurer pays.
Bethesda Naval Hospital. The National Naval Medical Center in Bethesda, Maryland, United States, is a hospital considered the flagship of the U.S. Navy's system of medical centers. A government-run federal hospital, with government paid doctors and other providers, it conducts medical and dental research, and provides health care to members of the military, members of Congress, as well as the president and his family, at their pleasure.
-C-
Capitated Payment. A set payment to a health care provider for a certain amount of time or type of treatment regardless of how much care the individual gets or needs. The provider's financial incentive is to deliver as few services as possible. The opposite of fee-for-service.
Carrier. The insurance company offering a health insurance policy.
Catastrophic Coverage. Insurance designed to protect an individual from having to pay very high out-of-pocket costs. Catastrophic coverage usually begins after the person has spent a high pre-determined amount.
Catastrophic Limit. The most amount of money an individual will have to pay out of pocket during a given period of time for certain services. After the person has reached the catastrophic limit, a higher level of coverage begins, though he or she may still have to pay some portion of health care costs. Not all out-of-pocket costs may count towards the catastrophic limit. Varies by plan.
Certificate of Insurance. The printed description of the benefits and coverage provisions forming the contract between a person and his or her carrier, which details what the plan covers, what it does not, and dollar limits.
Claim. A bill to an insurance company asking for payment for services or benefits a plan member received.
COBRA. The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that guarantees employees and their families who lose their employer-sponsored health coverage-due to termination of employment, death, divorce, or other circumstances-the right to purchase continued coverage under the employer's group health plan for limited periods of time. Qualified individuals are required to pay the entire premium for coverage plus an administrative fee, up to 102 percent of the cost of the plan. COBRA generally applies to people who worked for employers with 20 or more employees in the prior year.
Coinsurance. The portion of the cost of care you are required to pay after your health plan pays. Usually, it is a percentage (like 20 percent) of the amount approved by the insurer.
Conversion Policy. An employer-sponsored group health policy that can be converted to an individual policy with the same insurance company. These policies are usually very expensive.
Community Rating. A way to set insurance premiums that is based on the claims experience of people in the community. With community rating, each policyholder's premium is based on the average cost of the entire pool-healthy and sick mixed together-not on each individual's age or health status. The opposite of risk-based rating.
Copayment. A set amount (like $25) you are required to pay for each medical service you receive, such as a visit to your doctor.
Cost Sharing. Out-of-pocket costs for medical care or the portion of medical care that you pay yourself, such as a copayment, coinsurance or deductible. Premiums are not considered cost sharing.
Cost Tiers. A system that insurance plans use to set drug coverage cost sharing. Generic drugs are generally on the first, least expensive tier of the plan's formulary, followed by brand-name drugs, and then specialty drugs, with each subsequent tier requiring higher cost sharing.
-D-
Deductible. The amount of health care expenses you must pay before your health insurer begins to pay. Deductibles are generally for a calendar year.
Denial of Coverage. A refusal by your insurer to pay for medical services, usually because services are not covered by your policy, because you did not follow the plan's rules (such as getting pre-authorization for a service from the plan), or because the insurer does not consider the treatment medically necessary for you.
-E-
Effective Date. The date your insurance is set to actually begin. You are not covered until the policy's effective date.
Employer Waiting Period. Found in an employer group health plan, this is the amount of time a new employee must wait, often within three months of the first day of the full month the employee joins, before being eligible for health care coverage. This waiting period is imposed by the employer and is usually done to avoid "hit and run" behavior by a new employee, in which the employee files a large claim right after joining and then quickly leaves the company. [is this different from affiliation period because employer decides how much less than three months?]
Exclusion. Medical services that are not covered by your insurance policy.
Exclusion Period. The amount of time a new health plan member must wait to get coverage for care related to a pre-existing condition. The length of this type of waiting period can vary from one to 18 months.
Explanation of Benefits (EOB). The insurance company's written explanation of a claim, showing what it paid and what you must pay. If a claim is denied, the EOB will include a reason for the denial.
-F-
Fee-for-Service. Payment to doctors, hospitals and other health care providers for each service they give a patient. The provider's financial incentive is to give as many services as possible. The opposite of a capitated payment.
Federal Employees Health Benefits Program (FEHB). Health insurance benefits offered to employees of the federal government, including members of Congress. Like private employers, the government contracts with private insurance plans across the country to provide benefits to federal employees. The government subsidizes a portion of the premium of the plan the employee selects.
Formulary. The list of drugs a health insurance plan will cover at some level under particular circumstances.
-G-
Guaranteed Issue. A consumer protection offered by some states and the federal government for government insurance that gives people the right to buy health insurance coverage regardless of their age or health status.
Guaranteed Renewability. A consumer protection that gives people the right to keep their health insurance coverage regardless of their age or health status but at a price the insurer determines.
Group Insurance. A health insurance policy that is sold to cover a large number of people. Everyone in the group gets the same coverage for the same price. The insurance company spreads the risk equally among the healthy and the sick in the group.
-H-
HIPAA. The Health Insurance Portability and Accountability Act (HIPAA) amended the Employee Retirement Income Security Act (ERISA), to provide new rights and protections for members of group health plans. HIPAA contains protections both for health coverage offered in connection with employment (group health plans) and for the availability of individual insurance policies sold by insurance companies to people who previously had group coverage.
HMO (Health Maintenance Organization). A type of managed care plan that generally covers only the care you get from doctors, hospitals, and other health care providers that are in the plan's network. HMO members generally must choose a primary care doctor who acts as the 'gatekeeper,' deciding when they can go to a specialist.
-I-
In-Network. Doctors, hospitals and other health care providers that contract with a health plan to treat plan members. You usually pay less when using in-network providers, because they provide services at lower cost to the insurance companies with which they have contracts.
Indemnity Health Plan. These are the fee-for-service types of plans that primarily existed before the rise of managed care plans like HMOs. In an indemnity plan, you pay a pre-determined percentage of the cost of health care services, and the insurance company pays the other percentage. For example, you might pay 20 percent for services and the insurance company pays 80 percent. Indemnity health plans, also called “fee for service” plans give you the freedom to choose any health care provider.
Individual Insurance. A health insurance policy sold to an individual and not as part of a group. Individual insurance policies are generally regulated by the states, so rules vary widely across the country. Individual insurance policies are generally more expensive and less comprehensive than group policies.
-L-
Length of Stay (LOS). A term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.
Lifetime Maximum Benefit (or Maximum Lifetime Benefit). The maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime.
Limitations. A limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.
-M-
Managed Care. A medical delivery system, like an HMO or PPO that attempts to manage the quality and cost of medical services an individual receives.
Medicaid. A joint state and federal program that provides health care coverage to people with very low incomes who meet other eligibility criteria, such as being a child, being pregnant, being a single parent, having a disability, or being 65 years of age or older.
Medical Loss Ratio . The amount of premium revenues actually spent on paying for medical services. For example, if an insurance company spends 75 cents of every dollar it makes in premiums on paying for medical care for their policy holders, its medical loss ratio is 75 percent.
Medicare. The federal government program that provides health care coverage to people 65 years of age or older and people under 65 who have a disability, no matter their income or state of residence. The vast majority of people with Medicare (about 75 percent) get their medical benefits directly from the government-administered public program. The rest have joined a private insurance company that contracts with the government to provide benefits to people with Medicare.
Medical Underwriting. An insurance company practice that bases the premium and, sometimes the benefits, on an individual's own medical history. So the premium for people who are sick or who are likely to become sick (for example, people with diabetes) is higher than for people who are healthy.
Medically Necessary. Procedures, services, or equipment that meet good medical standards and are necessary for the diagnosis and treatment of a medical condition.
-N-
Network. A group of doctors, hospitals and other health care providers contracted to provide services to an insurance company's customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.
-O-
Out-of-Network. Doctors, hospitals and other health care providers that are not part of your insurance plan's network. If you get services from an out-of-network provider, it usually means that you will have to pay more out of your own pocket for the services you received.
Out-of-Pocket Costs. Health care costs that you must pay because your insurer does not cover them. Similar to cost sharing.
Out-Of-Pocket Maximum. A predetermined limit on the amount of money you must pay of your own money each year on medical costs before your insurance company will pay 100 percent of your health care expenses.
-P-
PCP (Primary Care Physician). The doctor that manages your care and refers you to specialty care if you need it. A managed care plan, like an HMO, generally requires you to have a PCP. If you don't consult your PCP before seeing a specialist, your managed care plan, will likely not cover your care. PCPs can be general or family practitioners, internists, pediatricians (for children) or gynecologists (for women).
POS Option (Point-of-Service Option). A type of HMO that provides plan members partial coverage for certain services they get outside the managed care plan network of providers.
PPO (Preferred Provider Organization). A type of managed care plan that should partially cover the care from out-of-network providers. To get full coverage, you must use network providers.
Pre-Admission Certification. Also called pre-certification review, or pre-admission review. Approval by an insurance company representative (usually a nurse) for you to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-admission certification often must be obtained by the individual. Sometimes, however, physicians will contact the appropriate individual. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary). In most plans, if you do not get pre-admission certification, the plan will not pay for the services provided.
Pre-Authorization: Also called "pre-approval." An approval that a managed care plan member must ask for from the plan or primary care doctor before getting certain medical services, such as an inpatient hospital stay. In some plans, if you do not get pre-authorization the plan will not pay for the care received.
Pre-Existing Condition. A medical condition or disease you have or had prior to joining the health plan. The exact definition of a pre-existing condition and how long a plan can look back in your medical history to find a pre-existing condition varies by the type of plan. For employer group plans, regulated by federal law, the health plan can only look back six months prior to your joining the plan and can only exclude coverage for your condition for up to 18 months. The amount of time the plan can exclude coverage depends on how long you were without coverage for that condition prior to joining the plan. For individual and small group plans, regulated by state law, the rules vary widely by state. Some states allow the plan to look back years into your medical history and exclude coverage for that condition forever; other states limit the health plans to looking back six months and exclude coverage for no more than six months.
Premium. The amount that you and/or your employer pays to an insurer for health care coverage, usually on a monthly basis.
Private Insurance. Insurance coverage provided by a non-governmental entity, where the private company takes on the risk of insuring its members. Can be for-profit or not-for-profit.
Public Plan. Insurance coverage provided directly by the government, where the government takes on the risk of insuring its members. It is always not-for-profit.
-R-
Reasonable and Customary Fees. The average fee charged by a particular type of health care provider within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, you may be responsible for paying the difference.
Referral. Authorization that HMOs and other managed care plans usually require for services not provided by your primary care doctor. For instance, HMOs generally require you to get a referral from your primary care doctor in order to see a specialist or get certain exams.
Rider. A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy (usually adding or excluding coverage).
Risk. The chance of loss, the degree of probability of loss, or the amount of possible loss to the insuring company.
Risk-Based Rating. Setting premiums based on an individual's likely health care needs. For example, somebody who already has diabetes or has a family history of diabetes would be charged more than somebody with no health problems. The difference in premiums would reflect the difference in expected health care costs for each policyholder. The opposite of community rating.
Risk Pooling. If health insurance works the way it should, it pools many people together to share (or spread) the costs (or risk) generated by a small number of people. The number of people covered makes up the 'pool' of people in the plan. Over the long run, risk pooling makes sense because almost everybody, eventually, needs expensive health care. It is more manageable to pay an average amount (or premium) every month than to get hit all at once by medical bills that reach tens or hundreds of thousands of dollars.
-S-
SCHIP. The State Children's Health Insurance Program (SCHIP) is a joint state and federal government program that provides health care coverage to families with children. The program was designed to cover uninsured children in families with incomes that are low, but too high to qualify for Medicaid. SCHIP benefits are provided through private insurance companies that contract with the state.
Service Area. The geographical area within which a health plan provides medical services to its members. In an HMO, it is the area where your network of doctors and hospitals is located.
Specialist. A physician who specializes in treating only a certain part of the body or a certain condition. For instance, a cardiologist only treats people with heart problems.
State Continuation Coverage. A law enacted in most states that extends COBRA-like rights to people who work for companies that have fewer than 20 employees. In some states, these laws apply to fully insured group coverage purchased by larger employers, as well. However, there is little uniformity between each of the states in regards to qualifying events, duration, covered benefits and the cost of state continuation coverage. Each state defines different qualifying events that trigger the right to continue group coverage. Depending on the state, these qualifying events are not necessarily the same as those under COBRA. Also, most states require people to have been covered under their group plan for a minimum period (such as three months) in order to be eligible for state continuation coverage. By contrast, COBRA only requires a person to have been covered under the group health plan on the day before the qualifying event.
-U-
Underwriter. The company or entity that assumes responsibility (is liable) for the risk of certain losses specified in the insurance policy, issues insurance policies and receives premiums.
Usual, Customary and Reasonable (UCR) Rates or Covered Expenses. An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.
Underwriter. The company or entity that assumes responsibility (is liable) for the risk of certain losses specified in the insurance policy, issues insurance policies and receives premiums.
-V-
Veterans Health Administration (VHA). The federal agency that provides health care to U.S. veterans. A closed, integrated health care system, the VHA owns and operates health care facilities around the country. The health care providers, doctors, nurses, etc., who provide health care in those facilities are employees of the VHA. Veterans can only get VHA covered care at VHA facilities. This type of health care system is known as socialized medicine. The VHA has used its integrated framework to create a model evidence-based quality-improvement program that delivers the highest quality care in the nation, as measured by adherence to established treatment protocols.
-W-
Waiting Period. The period of time specified in a health insurance policy that must pass before some or all of your health care coverage can begin.
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note: these are "generic" terms and terms can vary by state law from location to location. State insurance folks generally defer explinations to ERISA folks, meaning they lack the ablity or will to help folks in their varied insurance woes. That is why the insurance and health industry has had banner profits (estimates from 500 percent to 1000 percent in the last 7 years)
USW benefit department also has multiple woes in this area as does every other labor organization. Deck has been stacked against us and time for a "new deal" if you would
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Hard to keep up with verbage in the healthcare debate. Some folks do not understand some of the terms and this is a brief and good list from: http://www.insurancecompanyrules.org/pages/glossary/
Note: in our contract and benefit books, some of these "terms" are loose and subject to the "companies" interpretation; something not to our benefit. With the recient retiree loss in courts, companies and insurance folks have the upper hand in dealing with our folks (Rexam vs USW). This is not good for the average worker or retiree for the law protects companies and insurance companies against lawsuits.
Note: details of some of these lawsuits are in the files of our blog at: http://groups.yahoo.com/group/slsoarpac/files/
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-A-
Affiliation Period. The amount of time a new plan member must wait before being eligible for health care coverage, imposed by the health plan and not an employer. This waiting period cannot last longer than three months.
-B-
Balance Billing. When doctors and hospitals charge patients the difference between their fee and the amount their insurer pays.
Bethesda Naval Hospital. The National Naval Medical Center in Bethesda, Maryland, United States, is a hospital considered the flagship of the U.S. Navy's system of medical centers. A government-run federal hospital, with government paid doctors and other providers, it conducts medical and dental research, and provides health care to members of the military, members of Congress, as well as the president and his family, at their pleasure.
-C-
Capitated Payment. A set payment to a health care provider for a certain amount of time or type of treatment regardless of how much care the individual gets or needs. The provider's financial incentive is to deliver as few services as possible. The opposite of fee-for-service.
Carrier. The insurance company offering a health insurance policy.
Catastrophic Coverage. Insurance designed to protect an individual from having to pay very high out-of-pocket costs. Catastrophic coverage usually begins after the person has spent a high pre-determined amount.
Catastrophic Limit. The most amount of money an individual will have to pay out of pocket during a given period of time for certain services. After the person has reached the catastrophic limit, a higher level of coverage begins, though he or she may still have to pay some portion of health care costs. Not all out-of-pocket costs may count towards the catastrophic limit. Varies by plan.
Certificate of Insurance. The printed description of the benefits and coverage provisions forming the contract between a person and his or her carrier, which details what the plan covers, what it does not, and dollar limits.
Claim. A bill to an insurance company asking for payment for services or benefits a plan member received.
COBRA. The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that guarantees employees and their families who lose their employer-sponsored health coverage-due to termination of employment, death, divorce, or other circumstances-the right to purchase continued coverage under the employer's group health plan for limited periods of time. Qualified individuals are required to pay the entire premium for coverage plus an administrative fee, up to 102 percent of the cost of the plan. COBRA generally applies to people who worked for employers with 20 or more employees in the prior year.
Coinsurance. The portion of the cost of care you are required to pay after your health plan pays. Usually, it is a percentage (like 20 percent) of the amount approved by the insurer.
Conversion Policy. An employer-sponsored group health policy that can be converted to an individual policy with the same insurance company. These policies are usually very expensive.
Community Rating. A way to set insurance premiums that is based on the claims experience of people in the community. With community rating, each policyholder's premium is based on the average cost of the entire pool-healthy and sick mixed together-not on each individual's age or health status. The opposite of risk-based rating.
Copayment. A set amount (like $25) you are required to pay for each medical service you receive, such as a visit to your doctor.
Cost Sharing. Out-of-pocket costs for medical care or the portion of medical care that you pay yourself, such as a copayment, coinsurance or deductible. Premiums are not considered cost sharing.
Cost Tiers. A system that insurance plans use to set drug coverage cost sharing. Generic drugs are generally on the first, least expensive tier of the plan's formulary, followed by brand-name drugs, and then specialty drugs, with each subsequent tier requiring higher cost sharing.
-D-
Deductible. The amount of health care expenses you must pay before your health insurer begins to pay. Deductibles are generally for a calendar year.
Denial of Coverage. A refusal by your insurer to pay for medical services, usually because services are not covered by your policy, because you did not follow the plan's rules (such as getting pre-authorization for a service from the plan), or because the insurer does not consider the treatment medically necessary for you.
-E-
Effective Date. The date your insurance is set to actually begin. You are not covered until the policy's effective date.
Employer Waiting Period. Found in an employer group health plan, this is the amount of time a new employee must wait, often within three months of the first day of the full month the employee joins, before being eligible for health care coverage. This waiting period is imposed by the employer and is usually done to avoid "hit and run" behavior by a new employee, in which the employee files a large claim right after joining and then quickly leaves the company. [is this different from affiliation period because employer decides how much less than three months?]
Exclusion. Medical services that are not covered by your insurance policy.
Exclusion Period. The amount of time a new health plan member must wait to get coverage for care related to a pre-existing condition. The length of this type of waiting period can vary from one to 18 months.
Explanation of Benefits (EOB). The insurance company's written explanation of a claim, showing what it paid and what you must pay. If a claim is denied, the EOB will include a reason for the denial.
-F-
Fee-for-Service. Payment to doctors, hospitals and other health care providers for each service they give a patient. The provider's financial incentive is to give as many services as possible. The opposite of a capitated payment.
Federal Employees Health Benefits Program (FEHB). Health insurance benefits offered to employees of the federal government, including members of Congress. Like private employers, the government contracts with private insurance plans across the country to provide benefits to federal employees. The government subsidizes a portion of the premium of the plan the employee selects.
Formulary. The list of drugs a health insurance plan will cover at some level under particular circumstances.
-G-
Guaranteed Issue. A consumer protection offered by some states and the federal government for government insurance that gives people the right to buy health insurance coverage regardless of their age or health status.
Guaranteed Renewability. A consumer protection that gives people the right to keep their health insurance coverage regardless of their age or health status but at a price the insurer determines.
Group Insurance. A health insurance policy that is sold to cover a large number of people. Everyone in the group gets the same coverage for the same price. The insurance company spreads the risk equally among the healthy and the sick in the group.
-H-
HIPAA. The Health Insurance Portability and Accountability Act (HIPAA) amended the Employee Retirement Income Security Act (ERISA), to provide new rights and protections for members of group health plans. HIPAA contains protections both for health coverage offered in connection with employment (group health plans) and for the availability of individual insurance policies sold by insurance companies to people who previously had group coverage.
HMO (Health Maintenance Organization). A type of managed care plan that generally covers only the care you get from doctors, hospitals, and other health care providers that are in the plan's network. HMO members generally must choose a primary care doctor who acts as the 'gatekeeper,' deciding when they can go to a specialist.
-I-
In-Network. Doctors, hospitals and other health care providers that contract with a health plan to treat plan members. You usually pay less when using in-network providers, because they provide services at lower cost to the insurance companies with which they have contracts.
Indemnity Health Plan. These are the fee-for-service types of plans that primarily existed before the rise of managed care plans like HMOs. In an indemnity plan, you pay a pre-determined percentage of the cost of health care services, and the insurance company pays the other percentage. For example, you might pay 20 percent for services and the insurance company pays 80 percent. Indemnity health plans, also called “fee for service” plans give you the freedom to choose any health care provider.
Individual Insurance. A health insurance policy sold to an individual and not as part of a group. Individual insurance policies are generally regulated by the states, so rules vary widely across the country. Individual insurance policies are generally more expensive and less comprehensive than group policies.
-L-
Length of Stay (LOS). A term used by insurance companies, case managers and/or employers to describe the amount of time an individual stays in a hospital or in-patient facility.
Lifetime Maximum Benefit (or Maximum Lifetime Benefit). The maximum amount a health plan will pay in benefits to an insured individual during that individual's lifetime.
Limitations. A limit on the amount of benefits paid out for a particular covered expense, as disclosed on the Certificate of Insurance.
-M-
Managed Care. A medical delivery system, like an HMO or PPO that attempts to manage the quality and cost of medical services an individual receives.
Medicaid. A joint state and federal program that provides health care coverage to people with very low incomes who meet other eligibility criteria, such as being a child, being pregnant, being a single parent, having a disability, or being 65 years of age or older.
Medical Loss Ratio . The amount of premium revenues actually spent on paying for medical services. For example, if an insurance company spends 75 cents of every dollar it makes in premiums on paying for medical care for their policy holders, its medical loss ratio is 75 percent.
Medicare. The federal government program that provides health care coverage to people 65 years of age or older and people under 65 who have a disability, no matter their income or state of residence. The vast majority of people with Medicare (about 75 percent) get their medical benefits directly from the government-administered public program. The rest have joined a private insurance company that contracts with the government to provide benefits to people with Medicare.
Medical Underwriting. An insurance company practice that bases the premium and, sometimes the benefits, on an individual's own medical history. So the premium for people who are sick or who are likely to become sick (for example, people with diabetes) is higher than for people who are healthy.
Medically Necessary. Procedures, services, or equipment that meet good medical standards and are necessary for the diagnosis and treatment of a medical condition.
-N-
Network. A group of doctors, hospitals and other health care providers contracted to provide services to an insurance company's customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.
-O-
Out-of-Network. Doctors, hospitals and other health care providers that are not part of your insurance plan's network. If you get services from an out-of-network provider, it usually means that you will have to pay more out of your own pocket for the services you received.
Out-of-Pocket Costs. Health care costs that you must pay because your insurer does not cover them. Similar to cost sharing.
Out-Of-Pocket Maximum. A predetermined limit on the amount of money you must pay of your own money each year on medical costs before your insurance company will pay 100 percent of your health care expenses.
-P-
PCP (Primary Care Physician). The doctor that manages your care and refers you to specialty care if you need it. A managed care plan, like an HMO, generally requires you to have a PCP. If you don't consult your PCP before seeing a specialist, your managed care plan, will likely not cover your care. PCPs can be general or family practitioners, internists, pediatricians (for children) or gynecologists (for women).
POS Option (Point-of-Service Option). A type of HMO that provides plan members partial coverage for certain services they get outside the managed care plan network of providers.
PPO (Preferred Provider Organization). A type of managed care plan that should partially cover the care from out-of-network providers. To get full coverage, you must use network providers.
Pre-Admission Certification. Also called pre-certification review, or pre-admission review. Approval by an insurance company representative (usually a nurse) for you to be admitted to a hospital or in-patient facility, granted prior to the admittance. Pre-admission certification often must be obtained by the individual. Sometimes, however, physicians will contact the appropriate individual. The goal of pre-admission certification is to ensure that individuals are not exposed to inappropriate health care services (services that are medically unnecessary). In most plans, if you do not get pre-admission certification, the plan will not pay for the services provided.
Pre-Authorization: Also called "pre-approval." An approval that a managed care plan member must ask for from the plan or primary care doctor before getting certain medical services, such as an inpatient hospital stay. In some plans, if you do not get pre-authorization the plan will not pay for the care received.
Pre-Existing Condition. A medical condition or disease you have or had prior to joining the health plan. The exact definition of a pre-existing condition and how long a plan can look back in your medical history to find a pre-existing condition varies by the type of plan. For employer group plans, regulated by federal law, the health plan can only look back six months prior to your joining the plan and can only exclude coverage for your condition for up to 18 months. The amount of time the plan can exclude coverage depends on how long you were without coverage for that condition prior to joining the plan. For individual and small group plans, regulated by state law, the rules vary widely by state. Some states allow the plan to look back years into your medical history and exclude coverage for that condition forever; other states limit the health plans to looking back six months and exclude coverage for no more than six months.
Premium. The amount that you and/or your employer pays to an insurer for health care coverage, usually on a monthly basis.
Private Insurance. Insurance coverage provided by a non-governmental entity, where the private company takes on the risk of insuring its members. Can be for-profit or not-for-profit.
Public Plan. Insurance coverage provided directly by the government, where the government takes on the risk of insuring its members. It is always not-for-profit.
-R-
Reasonable and Customary Fees. The average fee charged by a particular type of health care provider within a geographic area. The term is often used by medical plans as the amount of money they will approve for a specific test or procedure. If the fees are higher than the approved amount, you may be responsible for paying the difference.
Referral. Authorization that HMOs and other managed care plans usually require for services not provided by your primary care doctor. For instance, HMOs generally require you to get a referral from your primary care doctor in order to see a specialist or get certain exams.
Rider. A modification made to a Certificate of Insurance regarding the clauses and provisions of a policy (usually adding or excluding coverage).
Risk. The chance of loss, the degree of probability of loss, or the amount of possible loss to the insuring company.
Risk-Based Rating. Setting premiums based on an individual's likely health care needs. For example, somebody who already has diabetes or has a family history of diabetes would be charged more than somebody with no health problems. The difference in premiums would reflect the difference in expected health care costs for each policyholder. The opposite of community rating.
Risk Pooling. If health insurance works the way it should, it pools many people together to share (or spread) the costs (or risk) generated by a small number of people. The number of people covered makes up the 'pool' of people in the plan. Over the long run, risk pooling makes sense because almost everybody, eventually, needs expensive health care. It is more manageable to pay an average amount (or premium) every month than to get hit all at once by medical bills that reach tens or hundreds of thousands of dollars.
-S-
SCHIP. The State Children's Health Insurance Program (SCHIP) is a joint state and federal government program that provides health care coverage to families with children. The program was designed to cover uninsured children in families with incomes that are low, but too high to qualify for Medicaid. SCHIP benefits are provided through private insurance companies that contract with the state.
Service Area. The geographical area within which a health plan provides medical services to its members. In an HMO, it is the area where your network of doctors and hospitals is located.
Specialist. A physician who specializes in treating only a certain part of the body or a certain condition. For instance, a cardiologist only treats people with heart problems.
State Continuation Coverage. A law enacted in most states that extends COBRA-like rights to people who work for companies that have fewer than 20 employees. In some states, these laws apply to fully insured group coverage purchased by larger employers, as well. However, there is little uniformity between each of the states in regards to qualifying events, duration, covered benefits and the cost of state continuation coverage. Each state defines different qualifying events that trigger the right to continue group coverage. Depending on the state, these qualifying events are not necessarily the same as those under COBRA. Also, most states require people to have been covered under their group plan for a minimum period (such as three months) in order to be eligible for state continuation coverage. By contrast, COBRA only requires a person to have been covered under the group health plan on the day before the qualifying event.
-U-
Underwriter. The company or entity that assumes responsibility (is liable) for the risk of certain losses specified in the insurance policy, issues insurance policies and receives premiums.
Usual, Customary and Reasonable (UCR) Rates or Covered Expenses. An amount customarily charged for or covered for similar services and supplies which are medically necessary, recommended by a doctor, or required for treatment.
Underwriter. The company or entity that assumes responsibility (is liable) for the risk of certain losses specified in the insurance policy, issues insurance policies and receives premiums.
-V-
Veterans Health Administration (VHA). The federal agency that provides health care to U.S. veterans. A closed, integrated health care system, the VHA owns and operates health care facilities around the country. The health care providers, doctors, nurses, etc., who provide health care in those facilities are employees of the VHA. Veterans can only get VHA covered care at VHA facilities. This type of health care system is known as socialized medicine. The VHA has used its integrated framework to create a model evidence-based quality-improvement program that delivers the highest quality care in the nation, as measured by adherence to established treatment protocols.
-W-
Waiting Period. The period of time specified in a health insurance policy that must pass before some or all of your health care coverage can begin.
------------------------
note: these are "generic" terms and terms can vary by state law from location to location. State insurance folks generally defer explinations to ERISA folks, meaning they lack the ablity or will to help folks in their varied insurance woes. That is why the insurance and health industry has had banner profits (estimates from 500 percent to 1000 percent in the last 7 years)
USW benefit department also has multiple woes in this area as does every other labor organization. Deck has been stacked against us and time for a "new deal" if you would
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