Health Insurance

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Health insurance is an insurance that covers the whole or a part of the risk of a person incurring medical expenses, spreading the risk over a large number of persons. By estimating the overall risk of health care and health system expenses over the risk pool, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to provide the money to pay for the health care benefits specified in the insurance agreement.^[1] The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity.

According to the Health Insurance Association of America, health insurance is defined as “coverage that provides for the payments of benefits as a result of sickness or injury. It includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment” (p. 225).^[2]

Background

A health insurance policy is:

A contract between an insurance provider (e.g. an insurance company or a government) and an individual or his/her sponsor (e.g. an employer or a community organization). The contract can be renewable (e.g. annually, monthly) or lifelong in the case of private insurance, or be mandatory for all citizens in the case of national plans. The type and amount of health care costs that will be covered by the health insurance provider are specified in writing, in a member contract or “Evidence of Coverage” booklet for private insurance, or in a national health policy for public insurance.
(US specific) Provided by an employer-sponsored self-funded ERISA plan. The company generally advertises that they have one of the big insurance companies. However, in an ERISA case, that insurance company “doesn’t engage in the act of insurance”, they just administer it. Therefore, ERISA plans are not subject to state laws. ERISA plans are governed by federal law under the jurisdiction of the US Department of Labor (USDOL). The specific benefits or coverage details are found in the Summary Plan Description (SPD). An appeal must go through the insurance company, then to the Employer’s Plan Fiduciary. If still required, the Fiduciary’s decision can be brought to the USDOL to review for ERISA compliance, and then file a lawsuit in federal court.

The individual insured person’s obligations may take several forms:^{[citation needed]}

Premium: The amount the policy-holder or their sponsor (e.g. an employer) pays to the health plan to purchase health coverage.
Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. For example, policy-holders might have to pay a $500 deductible per year, before any of their health care is covered by the health insurer. It may take several doctor’s visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care. Furthermore, most policies do not apply co-pays for doctor’s visits or prescriptions against your deductible.
Co-payment: The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service. For example, an insured person might pay a $45 co-payment for a doctor’s visit, or to obtain a prescription. A co-payment must be paid each time a particular service is obtained.
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. Billed items like use-and-throw, taxes, etc. are excluded from admissible claim. The insured are generally expected to pay the full cost of non-covered services out of their own pockets.
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 maxima. 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 maximum: 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 health insurance pays all further covered costs. Out-of-pocket maximum 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: (U.S. term) A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or co-payments, or additional benefits, to a plan member to see an in-network provider. Generally, providers in network are providers who have a contract with the insurer to accept rates further discounted from the “usual and customary” charges the insurer pays to out-of-network providers.
Prior Authorization: A certification or authorization that an insurer provides prior to medical service occurring. Obtaining an authorization means that the insurer is obligated to pay for the service, assuming it matches what was authorized. Many smaller, routine services do not require authorization.^[3]
Explanation of Benefits: A document that may be sent by an insurer to a patient explaining what was covered for a medical service, and how payment amount and patient responsibility amount were determined.^[3]

Prescription drug plans are a form of insurance offered through some health insurance plans. In the U.S., the patient usually pays a copayment and the prescription drug insurance part or all of the balance for drugs covered in the formulary of the plan. Such plans are routinely part of national health insurance programs. For example, in the province of Quebec, Canada, prescription drug insurance is universally required as part of the public health insurance plan, but may be purchased and administered either through private or group plans, or through the public plan.^[4]

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.

Statesboro

Statesboro is the largest city and county seat of Bulloch County, Georgia, United States,^[5] located in Southeast Georgia. A college town, Statesboro is best known as the home of Georgia Southern University, a Carnegie Doctoral-Research University.

As of 2015, the Statesboro Micropolitan Statistical Area, which consists of Bulloch County, had an estimated population of 72,651.^[6] The City itself had a population of 28,422 in the 2010 census.^[7] The City had an estimated 2015 population of 30,721.^[8]

The city was chartered in 1803, starting as a small trading community providing the basic essentials for surrounding cotton plantations. This drove the economy through the 19th century, both before and after the American Civil War.

In 1906, Statesboro and area leaders joined together to bid for and win the First District A&M School, a land grant college that eventually developed as Georgia Southern University in 1990. In 1908, Statesboro sold more cotton bales than did Savannah, Georgia, but the boll weevil infestation of the 1930s required a shift to tobacco as a crop. Statesboro inspired the blues song “Statesboro Blues“, written by Blind Willie McTell in the 1920s, and covered in a well-known version by The Allman Brothers Band.^[9]

In 1801, George Sibbald of Augusta donated a 9,301-acre (37.64 km²) tract for a centrally located county seat for the growing agricultural community of Bulloch County. The area was developed by white planters largely for cotton plantations, worked by slave labor. In December 1803, the Georgia legislature created the town of Statesborough. In 1866 the state legislature granted a permanent charter to the city, changing the spelling of its name to the present “Statesboro.”

During the Civil War and General William T. Sherman’s famous March to the Sea through Georgia, a Union officer asked a saloon proprietor for directions to Statesboro. The proprietor replied, “You are standing in the middle of town,” indicating its small size. The soldiers destroyed the courthouse, a crude log structure that doubled as a barn when court was not in session. After the Civil War, the small town began to grow, and Statesboro has developed as a major town in southeastern Georgia. Many freedmen stayed in the area, working on plantations as sharecroppers and tenant farmers.