Health Insurance Policy


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[7]: 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 US, 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 plan vs. health insurance Historically, HMOs tended to use the term "health plan", while commercial insurance companies used the term "health insurance". A health plan can also refer to a subscription-based medical care arrangement offered through health maintenance organization,HMO, PPO, or POS plan. These plans are similar to pre-paid dental, pre-paid legal, and pre-paid vision plans. Pre-paid health plans typically pay for a fixed number of services (for instance, $300 in preventive care, a certain number of days of hospice care or care in a skilled nursing facility, a fixed number of home health visits, a fixed number of spinal manipulation charges, etc.) The services offered are usually at the discretion of a utilization review nurse who is often contracted through the managed care entity providing the subscription health plan. This determination may be made either prior to or after hospital admission (concurrent utilization review). Inherent problems with insurance Insurance systems must typically deal with two inherent challenges: adverse selection, which affects any voluntary system, and ex-post moral hazard, which affects any insurance system in which a third party bears major responsibility for payment, whether that is an employer or the government. Some national systems with compulsory insurance utilize systems such as risk equalization and community rating to overcome these inherent problems.

Addiction Treatment Medication

Drug addiction treatment can include medications, behavioral therapies or a combination thereof. Treatment medications, such as methadone, buprenorphine and naltrexone, may help individuals addicted to opioids. Doctors prescribe nicotine preparations like patches, gum, lozenges and nasal spray and the medications varenicline and bupropion for individuals addicted to tobacco. Disulfiram, acamprosate, naltrexone and topiramate treat alcohol dependence, which commonly occurs with other drug addictions. In fact, most people with severe addiction are user many kinds of drugs and require treatment for all substances abused. Psychoactive medications, such as antidepressants, anti-anxiety agents, mood stabilizers and antipsychotic medications, may help patients have mental disorders, such as depression, anxiety disorders including post traumatic stress disorder, bipolar disorder or schizophrenia and a drug addiction problem.

Continuity of Care

Continuity of care is essential for drug abusers re-entering the community. Drug users who complete treatment in prison and continue with treatment in the community have low relapse rates. Continuing drug abuse treatment helps released offender deal with problems that become relevant only after prison, such as learning to handle situations that could lead to relapse, learning how to live without drugs in the community and how to develop a peer support network. Treatment in prison or jail can begin a process of therapeutic change, resulting in reduced drug use and criminal behavior after incarceration. Continuing drug treatment in the community is essential to sustaining abstinence.

Balanced Approach

A balance of rewards and sanctions encourages positive social behavior and treatment participation. When providing correctional supervision of individuals participating in drug abuse treatment, it is important to reinforce positive behavior. Nonmonetary social rewards such as recognition for progress or sincere effort are effective, as are graduated sanctions that are consistent, predictable and clear responses to noncompliant behavior. Generally, treatment specialists implement less punitive responses for early and less serious noncompliance, with increasingly severe sanctions issued for continued problem behavior. Rewards and sanctions are most likely to have the desired effect when they are fair and when they swiftly follow the targeted behavior.

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