According to statistics published by the Centers for Medicare and Medicaid Services, CMS, nearly 20% of Americans, more than 60 million persons, were enrolled in Medicaid programs during fiscal 2008. 50% of all Medicaid enrollees are children under the age of 18. This represents almost 40% of all children who live in the United States.
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By 2010, 47 million people were enrolled in Medicare. Nearly 85% of these, close to 40 million Medicare recipients are 65 or older. These two giant federally mandated and state-administered health care programs service the needs of more than a third of the total US population.
The U.S. population topped 307 million in 2009, according to the U.S. Census Bureau. So what health insurance options are available for the 200 or so million Americans who aren’t 65 years of age or don’t qualify for the low-income based Medicaid programs?
What are the largest private health insurance companies?
Available providers and program offerings vary from state to state and region to region within the United States. Health insurance organizations, as with all insurance companies, must be licensed in each state in which they intend to do business.
According to “U.S. News and World Report,” the top 25 U.S. health insurance concerns accounted for two thirds of the 650 billion dollars in premiums collected in 2009 by the nation’s largest health insurers.
The top five insurers in the U.S. are:
- Wellpoint, Inc.
- Kaiser Foundation Group
- Aetna Insurance
- Humana Group
The next five, in order, include:
- HCSC Group
- Coventry Corporation
- Independence Blue Cross
- Blue Shield of California Group
Number 11 on the list is the Cigna Group followed by a number of smaller insurance companies and regional blue cross and blue shield groups. Data for this survey comes from the National Association of Insurance Commissioners (NAIC).
What are some of the more popular health program options?
The two most popular private health insurance programs are managed care or HMO groups and PPO or personal provider type programs.
What is an HMO?
An HMO is a health maintenance or management organization designed to provide comprehensive medical services to its members. Members select a primary care physician, or PCP, who handles routine visits and checkups and refers a member for any additional medical needs, such as lab tests or x-rays.
A member’s PCP must also be consulted prior to any referral for specialized treatment or a surgical procedure. In an emergency, if at all practical, the member is expected to go to an authorized care center. However, referrals for emergency treatment are generally not required.
The principal benefit of an HMO is that all medical expenses are fully covered when provided within the managed network group of approved practitioners.
What is a PPO plan?
PPO groups are preferred provider organizations. They differ from HMO groups in that a member may seek medical services from any practitioner without obtaining a referral or obtaining authorization from a personal care physician. However, members of these groups will pay at least a part of the fees for each doctor visit or other covered medical service.
The portion of fees paid by subscribers, are called co-pays or co-payments. Depending on the group, co-pays can range from $5 to $50 or more, depending on the kind of service provided.
PPO groups also establish minimum and maximum out-of-pocket expenditures, called deductibles, which a member will be responsible for during a policy year. These amounts are set forth in the subscriber contract agreement.
What is a high deductible policy?
As a trade-off for reduced premiums, PPO groups will offer a high deductible option. In this program, a member agrees to pay 100% of initial medical expenses incurred, up to a maximum annual amount established in the subscriber contract.
These amounts usually range from $12 hundred to $15 hundred. Once a deductible limit is reached, normal co-pays will apply to future services.
Are there other options?
Some companies offer a third option, a POS, or point of service plan. This type of program combines the regulations and benefits of the HMO and PPO programs discussed earlier. For more detailed information, contact your local providers.
In addition to basic plans, riders are often available for dental coverage as well as vision and hearing. Some basic health plans provide partial coverage for eye exams and glasses or contact lenses. Dental services however, are usually covered by separate policies and contracts.
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