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Health Insurance: Health Insurance in Foreign (Part 03)
shofiq uddin khan
I complete my BBA from PSTU. 
By shofiq uddin khan
Published on 15 January 2010
How Health Insurance Works in Foreign (Premium, Deductible, Copayment, Coinsurance, Exclusions, Coverage limits, Out-of-pocket maximums). Common Features About Private Health Insurance in Foreign.

How Health Insurance Works in Foreign
How Health Insurance Works in Foreign

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:

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.

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.

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

Health Insurance companies are now offering Health Incentive accounts (HIA), to reward users for living healthy and making healthy choices, like stop smoking and/or losing weight, may get you funds added into your Health Incentive Account, which may lower your out of pocket costs. The health incentive accounts also carry over from year to year but once you leave the program you lose those benefits in the HIA.

Some Common Features About Private Health Insurance in Foreign

1. Insurance companies usually only re-price their coverage annually. 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. Exceptions to this differential in pricing can be found when an individual (and their dependents) become insured under a pre-existing pool of insured’s 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, insured’s 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. 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.

4. Health insurance is often only widely available at a reasonable cost through an employer-sponsored group plan and online for individuals.

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.

6. Experimental treatments are generally not covered. This practice is especially criticized by those who have already tried, and not benefited from, all "standard" medical treatments for their condition.

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.

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. The health care company has popular and unpopular ways of controlling this market force.

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.

10. Unlike most publicly funded health insurance, many private insurance plans do not provide coverage of dental health care, or only offer such coverage with additional premiums and very low dollar-amount coverage’s.

11. 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.