Health Insurance PDF

Health Insurance 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 numerous persons. According to the Health Insurance Association of America, health insurance is defined as "coverage tha...

Health Insurance 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 numerous persons. 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 Seeking medical treatment for illnesses or accidents would be very expensive without health insurance Health insurance offsets the cost of doctor bills, surgery, hospital, laboratory and x-ray fees, and pharmacy costs Health Insurance Policy A contract between an insurance provider (e.g. an insurance company or a government) and an individual or his/her sponsor (that is an employer or a community organization). The type and amount of health care costs that will be covered by the health insurance provider are specified in writing contract Forms of health insurance 1. Premium: The amount the policy-holder or their sponsor (e.g. an employer) pays to the health plan to purchase health coverage According to the healthcare law, a premium using 5 specific factors regarding the insured person (age, location, tobacco use, individual vs. family enrollment, plan category the insured chooses) 2. Deductible: The amount that the insured must pay out-of-pocket before the health insurer pays its share. 3. Co-payment: The amount that the insured person must pay out of pocket before the health insurer pays for a particular visit or service. 4.Coinsurance: is a percentage of the total cost that insured person may also pay. 5.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 6. Coverage limits: Some health insurance policies only pay for health care up to a certain cost amount. The insured person may be expected to pay any charges in excess of the health plan's maximum payment for a specific service.  7. 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 (prescription drugs) Explaining How to Choose a Health Plan Reasons for Health insurance - Fast Lifestyle - Diseases common in children - Food Habits - Lack of Exercise - Mental Stress & Strain - Pollution - New Types of Diseases (unexpected like Accidents) Importance of Health Insurance Rising of medical cost Sharing for health risk Uncertain hospital bills Expensive/ quality of health care services Money value – health vs illness Tax benefits Productivity of workforce Decrease government burden  Rising Health Care Costs  Specialty health care  Investigative type of treatment  Hospital infrastructure  Medical equipment  Cost of living/Inflation  Rising drug prices  Defensive Medical practice Why is health insurance essential? - Unaffordable health care - No basic public health services - Increasing life expectancy - Increasing percentage of the elderly persons - Health is wealth Challenges for Insurance companies - Low level of consumer awareness - Limited product development - Limited knowledge for staff/Agents - Pricing demands from Insurance companies - Lack of proper communication between TPAs and Hospitals - Lack of Training support from Insurers as well as TPAs - Different Insurance Companies – different policies, terms etc Benefits to the public - Developing insurance awareness - Selection of suitable insurance policies - No immediate cash out of- pocket - Tension free claim settlement process Health Insurance in Sudan Sudan is a lower middle income country. It spends about 6.5% of its Gross Domestic Product (GDP) and 8.2% of the general government expenditure on health. Out-of-pocket share is about 70% (US$84.0 per capita) while the general government heath expenditure represents only 22.3% (US$26.9 per capita). Social Health Insurance (SHI) was implemented in Sudan in 1997 as an attempt to overcome the problem of accessibility. In 2017, SHI reached 71.5% coverage in Khartoum State (966,728 families out of 1,351,514 families) and 50.7% overall coverage in the rest of the states (16,012,805 out of 31,583, 869 individuals). About 5.5% of the population is covered by other health insurance schemes such as police, military and para-statal organizations Membership of National Health Insurance Fund (NHIF) is compulsory for the formal sector, while it is voluntary for the informal sector and small companies (≤10 employees) Assignment: Health Insurance forms and polices in Sudan