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How does medical insurance work?
Medical insurance is a policy designed to assist offset the prices of medical treatment by covering a portion of the skilled and hospital fees incurred. Based on the federal government’s medical insurance exchange website HeatlhCare.gov, any such coverage is available in several forms aimed toward meeting the various needs of policyholders.
“Some varieties of plans restrict your provider selections or encourage you to get care from the plan’s network of doctors, hospitals, pharmacies, and other medical service providers,” the positioning explained. “Others pay a greater share of costs for providers outside the plan’s network.”
Among the many sorts of policies currently available out there, based on HealthCare.gov are:
- Exclusive Provider Organization (EPO): This can be a managed care plan where services are covered provided that the doctors, specialists, or hospitals are within the plan’s network – except in cases of emergency.
- Health Maintenance Organization (HMO): Any such medical insurance plan often limits coverage to care from doctors who work for or are contracted with the HMO. Policies generally don’t cover out-of-network care except in an emergency. Plans may likewise require that a policyholder live or work in its service area to be eligible for coverage. HMOs typically provide integrated care and concentrate on prevention and wellness.
- Point of Service (POS): In this type of policy, policyholders pay less in the event that they access doctors, hospitals, and other healthcare providers belonging to the plan’s network. POS coverage also requires the insured to get a referral from their primary care doctor for them to see a specialist.
- Preferred Provider Organization (PPO): This health plan allows policyholders to pay less for healthcare in the event that they decide to get treatment from providers within the plan’s network. Nonetheless, they also can access doctors, hospitals, and providers outside of the network with no referral for an extra cost.
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Medical insurance plans are also offered in 4 categories based on how the prices are split between the policyholder and the insurer. These are Bronze, Silver, Gold, and Platinum. HealthCare.gov noted, nonetheless, that the category “[has] nothing to do with [the] quality of care.”
Below is the estimated split for every category.
Bronze plans have the bottom monthly premiums, but policyholders might want to pay higher out-of-pocket costs before the policy kicks in. The alternative is true for Platinum coverage, which has the costliest rates but the most affordable deductibles.
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What does medical insurance cover?
Considered one of the changes the Reasonably priced Care Act (ACA) has implemented within the country’s healthcare system is the standardization of insurance plan advantages. Prior to this, the advantages offered by insurers varied significantly between policies. Currently, US medical insurance plans are required to cover a listing of 10 “essential health advantages,” consisting of:
- Ambulatory patient services
- Emergency services
- Pregnancy, maternity, and newborn care
- Mental health and substance use disorder services, including behavioral health treatment
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including oral and vision care
Dental and eye care coverages for adults usually are not considered essential advantages but can be found as optional add-ons, together with medical management programs.
Contraception and breastfeeding coverage, meanwhile, are also required advantages.
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How much does medical insurance cost?
Based on HealthCare.gov, insurance firms can only account for five aspects when determining premiums under the healthcare law. These are:
Age: Premiums could be as much as thrice higher for older people than for younger ones.
Location: Differences in competition, state, local regulations, and price of living also impact medical insurance rates.
Tobacco use: Insurers can charge tobacco users as much as 50% greater than those that don’t smoke.
Individual vs. family enrollment: Insurance providers also can charge more for a plan that also covers a spouse and dependents.
Plan category: The various plan categories – Bronze, Silver, Gold, and Platinum – also has an effect on premium prices.
The federal government website noted that states can limit how much impact these aspects have on insurance rates but prohibited them from using medical history and gender in calculating premiums.
“Insurance firms can’t charge ladies and men different prices for a similar plan,” HealthCare.gov explained. “In addition they can’t take your current health or medical history into consideration. All health plans must cover treatment for pre-existing conditions from the day coverage starts.”
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What are the highest medical insurance firms within the US?
The ten leading medical insurance firms within the US wrote almost 57% of all policies out there, based on the most recent figures from the National Association of Insurance Commissioners (NAIC), with those in the highest five accounting for 41%.
These providers offer basic medical insurance products to individuals and businesses – together with other services that may include Medicaid and Medicare policies, long-term care insurance, dental coverage, and vision advantages.
These are the most important medical insurance providers within the country ranked based on direct written premiums based on NAIC’s data.
1. UnitedHealth Group
Headquarters: Minnetonka, Minnesota
Direct written premiums: $195.4 billion
Market share: 14.47%
Memberships: 49.5 million
States available: Nationwide
A diversified health and well-being company, UnitedHealth Group’s core capabilities are clinical expertise, advanced technology, and data and health information.
UnitedHealth serves clients and consumers within the US and greater than 130 other countries through two distinct platforms. UnitedHealthcare, which boasts a network of greater than 1.3 million physicians and healthcare professionals and 6,500 hospitals, provides healthcare coverage and advantages, while Optum offers information and technology-enabled health services. The group invests greater than $4 billion in technology and innovation and processes roughly 1.1 trillion transactions annually.
2. Kaiser Foundation
Headquarters: San Francisco, California
Direct written premiums: $107.8 billion
Market share: 7.98%
Memberships: 12.6 million
States available: All or parts of California, Colorado, Georgia, Hawaii, Maryland, Oregon, Virginia, Washington, Washington, D.C.
Kaiser Foundation Health Plan, Inc. operates as a non-profit healthcare organization. The organization provides budget-based plans, which may cover allergy, audiology, cardiology, dermatology, oncology, hospice, laboratory, nephrology, occupational therapy, pain management, pediatric rehabilitation, and pharmacy services. The insurer’s policies include lower premiums and no deductibles and includes pharmaceuticals.
3. Elevance Health (formerly Anthem)
Headquarters: Indianapolis, Indiana
Direct written premiums: $93.8 billion
Market share: 6.95%
Memberships: Greater than 32 million
States available: California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, Latest Hampshire, Latest York, Ohio, Virginia, Wisconsin
Anthem modified its name to Elevance Health in June 2022. The health insurer provides medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans through affiliated firms, including Anthem Blue Cross and Blue Shield, Empire BlueCross BlueShield in Latest York, Anthem Blue Cross in California, Wellpoint, and Carelon. Elevance Health boasts a network of 1.7 million doctors and hospitals in 14 states and is the most important for-profit managed health care company within the Blue Cross Blue Shield Association.
Headquarters: St. Louis, Missouri
Direct written premiums: $82.4 billion
Market share: 6.10%
Memberships: Greater than 26 million
States available: 29 states, including California, Florida, Latest York, and Texas – 4 of the most important Medicaid states
Centene Corporation, a Fortune 500 company, is a diversified, multinational healthcare firm providing a portfolio of services to government-sponsored healthcare programs, specializing in uninsured and underinsured individuals. It’s currently the most important Medicaid managed care organization within the country.
Centene operates local health plans and provides a spread of medical insurance products. It also partners with other healthcare and business groups to supply specialty services, starting from behavioral health, dental advantages, life and health, and pharmacy advantages management to care management software, correctional healthcare services, in-home health services, managed vision, specialty pharmacy, and telehealth services.
Headquarters: Louisville, Kentucky
Direct written premiums: $79.6 billion
Market share: 5.90%
Memberships: Greater than 20 million
States available: Nationwide
Humana’s cultural foundation is aligned with helping members achieve their best health by providing personalized, simplified, whole-person healthcare experiences. Recognizing that everyone, family, and community’s healthcare needs proceed to evolve, Humana creates revolutionary solutions and resources to assist people live the healthiest lives on their terms – when and where they need it.
6. CVS Health
Headquarters: Woonsocket, Rhode Island
Direct written premiums: $74.3 billion
Market share: 5.51%
Memberships: Greater than 23 million (medical advantages)
States available: Nationwide
CVS Health is a healthcare innovation company, which goals to assist people on their path to higher health. It has greater than 9,900 retail locations, nearly 1,100 walk-in medical clinics, a pharmacy advantages manager with about 100 million plan members, a diversified healthcare advantages company serving over 23 million medical members, a dedicated senior pharmacy care business serving a couple of million patients per 12 months, expanding specialty pharmacy services, and a standalone Medicare Part D prescription drug plan.
Headquarters: Chicago, Illinois
Direct written premiums: $46.5 billion
Market share: 3.44%
Memberships: About 17 million
States available: Illinois, Montana, Latest Mexico, Oklahoma, Texas
Health Care Service Corporation (HCSC), a mutual legal reserve company, is the most important customer-owned healthcare insurance company within the US. The corporate offers a wide range of life and medical insurance products and related services through its affiliates and subsidiaries, including Dearborn Group, Dental Network of America, HCSC Insurance Service Company, Medecision, Availity, Prime Therapeutics, and TriWest Healthcare Alliance.
Headquarters: Bloomfield, Connecticut
Direct written premiums: $34.1 billion
Market share: 2.53%
Memberships: Greater than 17 million
States available: Arizona, Colorado, Florida, Illinois, Kansas, Missouri, North Carolina, Tennessee, Utah, Virginia
Cigna’s insurance coverage and products include healthcare insurance for people and families, dental insurance coverage, Medicare plans, Medicare supplemental plans, other supplemental insurance, and international medical insurance.
9. Molina Healthcare
Headquarters: Long Beach, California
Direct written premiums: $26.5 billion
Market share: 1.97%
Memberships: About 4 million
States available: Arizona, California, Florida, Idaho, Illinois, Kentucky, Massachusetts, Michigan, Mississippi, Ohio, Nevada, Latest Mexico, Latest York, South Carolina, Texas, Utah, Virginia, Washington, Wisconsin
Molina Healthcare, a Fortune 500 company, exclusively focuses on government-sponsored healthcare programs for qualified individuals and families. The corporate partners with state governments and serves as a health plan providing a big selection of quality healthcare services to individuals and families. It also offers a Medicare product and has been chosen in lots of states to affix in dual demonstration projects to administer the take care of those eligible for Medicaid and Medicare.
10. Independence Health Group
Headquarters: Philadelphia, Pennsylvania
Direct written premiums: $22.8 billion
Market share: 1.69%
Memberships: Greater than eight million
States available: Southeastern Pennsylvania, 27 states through affiliates
Independence Health Group, together with its subsidiaries, serves clients in 27 states and the District of Columbia. 1 / 4 of its customer network relies in southeastern Pennsylvania. The corporate serves various employer groups, from SMEs to national corporations. Among the many services the insurer offers are business, Medicare and Medicaid coverage, pharmacy advantages management, employees’ compensation, and third-party advantages administration. The corporate is an independent licensee of the Blue Cross and Blue Shield Association.