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Health Insurance 101

Hospital administrators often have to deal with insurance paperwork and calls to insurance companies. Even if they don’t deal with these matters on a day-to-day basis, they still need to understand how various types of insurance programs work.

Many patients may be covered primarily or entirely by private insurance, however, there are also many who are covered at least in part by government healthcare programs like Medicare and Medicaid. To get a basic understanding of the options available to patients, let’s take a look at the different categories.

Private insurance

Private insurance is often offered through the patient’s employer, whether there is a single plan available or multiple options. This means that the average American’s health insurance plan could change each time he or she changes jobs. It is also possible for patients to buy their own insurance on the healthcare market.

Insurance plans frequently operate through the model of a health maintenance organization (HMO) or preferred provider organization (PPO). The former generally requires patients to receive their care within a specific network of healthcare providers, while the latter allows one to receive at least some coverage from out-of-network providers.

What are Medicare and Medicaid?

There are several avenues for receiving insurance outside of the private marketplace. Medicare is a form of health insurance for individuals over the age of 65, eligible younger individuals with disabilities, and those suffering from End-Stage-Renal-Disease. Medicare benefits are determined by different categories from Part A to Part D.

Medicaid is another public health insurance program, but one that is based on income. It acts as the biggest single health insurance source in the U.S. The Affordable Care Act of 2010 (ACA) greatly expanded Medicaid eligibility to cover individuals who would have previously exceeded Medicaid income eligibility limits.

What are state exchanges?

Another aspect of ACA was to develop government-run marketplaces for individuals to purchase health insurance. Some states run their own marketplaces, while others do not. Individuals in states where there is no state-run marketplace can purchase their plans through Healthcare.gov.

What about other public health insurance programs?

You may be wondering about other forms of health insurance that you’ve heard of, such as the Children’s Health Insurance Program (CHIP) or care offered through the Veterans Health Administration (VA).

CHIP is a program offered in every state, that provides health insurance to some children who do not qualify for Medicaid. However, CHIP programs work closely with Medicaid. In some situations, CHIP may cover pregnant mothers as well.

The VA offers healthcare and variety of other services to Americans who have served in the military. They have certain resources that are particularly relevant to veterans, such as treatment for Post Traumatic Stress Disorder and benefits for individuals exposed to the herbicide Agent Orange during the Vietnam and Korean wars

This list is by no means a complete rundown of health insurance programs in the U.S. However, it should give would-be hospital administrators a good idea of the types of benefits that patients may be receiving when they come into a facility for medical treatment.