Health Insurance in Redding, CA

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Health Insurance In Redding, California

Health insurance, like other forms of insurance, is a form of collectivism by means of which people collectively pool their risk, in this case the risk of incurring medical expenses. The collective can be a non-profit established for the members of the pool or it can be a for-profit company.  Heath insurance can also include covering long-term nursing, custodial care need and disability. It can be purchased as an individual or as a group (such as an employers plan). In either case, premiums are paid to help protect them from unexpected healthcare expenses.  By estimating the overall risk of healthcare expenses, a financial structure (premiums) is developed ensuring that money is available to pay for the healthcare benefits specified in the insurance agreement. The benefits are administered by a central organization such as a government agency, private business, or non-profit entity.

Insurance for some is provided through the government via Medicaid or Medicare.  Medicaid is for eligible individual and families with low incomes and is jointly funded by the state and federal governments and is managed by the states.  Medicare is a federal program providing health insurance coverage to people who are aged 65 and over, or who meet other special circumstances.

How it works

A health insurance policy is a contract between an insurance company and an individual or a group (i.e. employer). The contract can be renewable annually or monthly. The type and amount of health care costs that will be covered by the health insurance company are specified in advance, in the member contract or "Evidence of Coverage" booklet. The individual insured person's obligations may take several forms.

  • Premium:The amount the policy-holder or his sponsor (e.g. an employer) pays to the health plan each month to purchase health coverage.
  • Deductible: The out-of-pocket amount the insurer pays prior to the insurance company pays. An example would be if you policy has a $1000 deductible, the insured must pay $1000 in covered health expenses before the insurance company will start paying for covered items.  Covered expenses could include doctor visits, chiropractic visits, prescriptions or other cover expenses.
  • Co-payment:The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service.   An example of this is when the insured has a co-payment of $20 for doctor visits.  That would mean for each visit to the doctors, the insured will pay $20 to the provider and the insurance company would cover the remainder of the cost.
  • Coinsurance:Instead of, or in addition to, paying a fixed amount up front (a co-payment), the co-insurance is a percentage of the total cost that insured person may also pay. For example, the member might have to pay 20% of the cost of a surgery over and above a co-payment, while the insurance company pays the other 80%. If there is an upper limit on coinsurance, the policy-holder could end up owing very little, or a great deal, depending on the actual costs of the services they obtain.
  • Exclusions:Not all services are covered. The insured person is generally expected to pay the full cost of non-covered services out of their own pocket.
  • Coverage limits:Some health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some insurance company schemes 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 insured person's payment obligation ends when they reach the out-of-pocket maximum, and the health company 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.
  • Capitation:An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer.
  • In-Network Provider:Health insurances in the United States have created pre-selected lists of health care providers whom the insured can render services from.  The insurance company often offers discounts or may pay additional benefits when the insured uses a provider on their list or “In-Network Provider.”
  • Prior Authorization: When the insured is in need of a service not generally covered by the contract between the insurance company and patient, a prior authorization is obtained.  With this prior authorization, the insurance company is agreeing to pay for the non-covered services.
  • Explanation of Benefits: A document sent by an insurer to a patient explaining what was covered for a medical service, and how they arrived at the payment amount and patient responsibility amount.

Prescription drug plans are a form of insurance offered through some employer benefit plans in the U.S., where the patient pays a copayment and the prescription drug insurance part or all of the balance for drugs covered in the list of approved drugs. .

Some, if not most, health care providers in the United States 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. The insurance company pays out of network providers according to "reasonable and customary" charges, which may be less than the provider's usual fee. The provider may also have a separate contract with the insurer to accept what amounts to a discounted rate or capitation to the provider's standard charges. It generally costs the patient less to use an in-network provider.


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