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Health insurance may be defined as a ‘type of insurance coverage that covers the (total or near total) cost of an insured individual’s surgical treatment and other medical expenses.’

In health insurance parlance, the insurance company generally uses the term “provider” to best describe any medical care facility such as a clinic, doctor, laboratory, hospital, healthcare practitioner, or even a pharmacy that treats an affected individual or the “insured” person, i.e., the person who is actually the owner of the health insurance policy or alternatively, someone who has been given health insurance coverage. Please call us at 407-344-1228, or email us at [email protected] for any insurance needs you may have.

  • The Health Insurance Contract

This coverage is in the form of a contract between the insurance carrier or provider (either an insurance company, or the government) and an individual. This contract can even be signed between the insuree and his/her sponsor such as an employer or a community organization.

Furthermore, almost all such contracts are freely renewable. That is, they can be renewed monthly or annually or they may even be lifelong health insurance contracts. This last holds particularly true when the state makes health insurance mandatory for all the citizens of that country. The total insurance amount to be paid (in case a claim is made) as well as the nature and scope of the contract will be specified at the time of signing the contract. 

  • How Does an Insurance Contract Work?

Once again, depending on the nature, type and scope of the health insurance coverage, either the insured person pays the cost of the treatment out of his pocket and receives reimbursement in return, or alternately, the insurer will make all necessary makes payments directly to the medical treatment provider.

In countries that do not enjoy universal health and medical care coverage, such as the US, health and medical insurance is generally included as part of the employee benefit packages at the time of joining the organization.

Health insurance in Kissimmee, FL, typically includes insurance for any losses resulting from accidents, disability, medical expenses, or even accidental death and dismemberment (the permanent loss of a limb). 

  • The Roles and Responsibilities of The Insured Individual

The insured person’s individual legal and financial commitments may take several forms. Let us take a quick look at a few such obligations:

  • Premium

This is the total amount the policyholder (or the organization that is sponsoring the policy) will pay for health insurance in Kissimmee, FL. Premium payments are the price of coverage and they may be paid either monthly, annually or  once in a lifetime, depending on the type of the policy.

  • Deductibles

This is the amount that the insured party has to pay on his own, before the company providing health insurance in Kissimmee, FL, will entertain his compensation claim. For example, the insurance policyholder may have to pay a sum of $300 deductible per annum, before they can make any claims to their health insurance service provider.

However, it is likely that there will be multiple visits to a health care facility for doctor’s consultations and prescription refills before the policyholder will reach the deductibles stage and his service provider will commence paying for his care. Moreover, there are many policies that do not apply against the deductibles of the policy, especially with regard to prescription refills and doctor’s visits.

  • Co-Payments

This is the total amount that the policyholder has to pay out of his own pocket before the company providing health insurance in Kissimmee, FL starts paying for any specific visit or service. For example, an insured person may have to pay an amount of $30 as co-payment for a visit to his doctor or for going to the pharmacy for getting a prescription refilled.  In either case, it is important that the co-payment must always be paid every time any particular service has been obtained.

This is a different form of health insurance in Kissimmee FL. Here, in addition to paying a pre-specified fixed amount right up front. The policyholder will be able to obtain the co-insurance coverage at a particular percentage of the sum total cost that he might have to pay otherwise.

For example, if the policy maintains an 80/20% payment parity policy, then the insured party will only have to pay around twenty percent of the total cost of treatment, over and above the co-payment amount. The insurance company will be responsible for paying the remaining eighty percent.

Basically, co-insurance means that both the service provider as well as the policyholder split any compensation claim for health insurance in Kissimmee, FL. The percentages are already decided beforehand.  But the common terms and conditions usually call for a 70 to 30 percent split, with the insurance agency paying the larger amount.   

  • Exclusions

When you acquire a health insurance policy, that does not mean that you are completely covered in every aspect of your physical well-being. For example, your policy may not include cataract removal or loss of a limb (dismemberment). Apart from that, various billed items such as ‘use and throw syringes, disposable articles, taxes, etc., might be excluded from the compensation claim. Here, it is pertinent to note that the insured individual is almost always expected to pay the total cost of non-covered services, on his own.

  • Total Coverage Limit

Some health insurance policies are amount specific. That is they may pay for all medical expenses up to a certain dollar limit.  In this case, the insured individual will be expected to pay the extra charges that are in excess of the original policy’s maximum payment for any specific service.

  • Example

Mrs. Smith is having a baby, and she wants a private room at the hospital. The cost of the room is $ 250 per night. But her pregnancy plan allows only $200 per room per night. Either she will have to shift to a general ward or a semi private room, or alternately, she will have to pay the amount that is over and above her policy limit. 

Additionally, certain insurance companies also have products and schemes that have an annual or even ‘lifetime coverage maxima’. In all such cases, the major health plan will almost certainly stop the payments to their policyholders once they reach the ‘benefit maximum’. This means that the policyholder has to pay all remaining costs from his own pocket.

  • Out of Pocket Maxima

This form of payment place is quite similar to the ‘coverage limit’ option. However, there is a cravat attached. The insured person’s total payment obligation will end once he or she will reach the ‘out of pocket maxima.’ Once that happens, the company providing health insurance in Kissimmee FL, will pay all further costs that are already covered in the original policy.

Here, it is pertinent to note that just about all out of pocket maxima coverage may be limited to a very specific benefit category (prescription drugs, for instance). Alternatively, it can also apply to the health coverage provided during a particular benefit year.

  • Capitation

This is the total amount paid by an insurer to his or her health care service provider. The service provider will sign an agreement to treat all the members of the policy against this coverage.

  • In-Network Provider

This is a term used only by American insurance agencies. A health care provider will be part of a ‘panel’ or list of providers that have already been preselected by the insurance agency. Here, the insurer will automatically offer discounted co-payments, co-insurance or any other additional benefits to a policyholder who seeks treatment from any in-network (health care) provider. As a general rule, the ‘providers in network’ are those health and medical care providers who already have a specific contract with the insurance company to accept discounted rates from their usual charges. That is, they offer discounts over and above what the policyholder would pay to ‘out of network’ health care providers.

  • Prior Authorization

Prior Authorization is an authorization or certification that an insurance company provides to the health care facility just prior to utilizing any medical services mentioned in the health insurance policy. Once an authorization has been obtained, the insurance agency will automatically be obligated to pay for the services used, assuming that the utilization matched the services in the original authorization letter or contract. This generally applies to major expenses, such as costly surgeries and related treatments. Most small and routine services generally do not require any sort of prior authorization. 

  • Explanation of Benefits

Any document that may be sent by the insurance service provider to a policyholder to determine and explain the extent of the coverage is known as an ‘explanation of benefits’ letter. It will show the payment amount and also determine the amount that the policyholder is obliged to pay to the medical facility.

  • Major Types of Health Insurance Polices

Broadly defined, there are two main types of health insurance plans currently available today.

  • Private Health Insurance

According to the Center for Disease Control and Prevention (CDC) the U.S. healthcare system basically relies quite heavily on private health insurance agencies in most parts of the country. As a matter of fact, various surveys have determined that the vast majority of US citizens have at least some sort of private health insurance coverage.

  • Government or Public Health Insurance

In this type of health insurance plan, the government actively subsidizes healthcare in exchange for a pre-decided (annual) premium. Some of the more common examples of health insurance include the following:

  • Medicare
  • Veteran’s Health Administration
  • Medicaid
  • The Indian Health Service

Apart from the above two categories, there are several other types of insurance plans and policies currently in vogue in the US today.

  • Managed Care Plans

In this type of insurance plan, the insurance company will have signed contracts with their own network of primary, secondary and tertiary healthcare service facilities. The goal is to give lower-cost medical care to all of their health insurance policyholders. There will be stiff penalties, not to mention the burden of additional costs that will be added in case the policyholder opts for a hospital or clinic that is not part of the policyholder’s network.  Here it is pertinent to note that the more expensive the insurance policy (in terms of annual premium payments), the larger will be its network panel of health care service providers.

  • Fee for Service or Indemnity Plans

A ‘fee for service’ health insurance plan will cover all medical treatments equally amongst the different healthcare providers. This means that the insured will be able to choose their own preferred clinic or hospital. In this case, it is the insurance company that will generally pay eighty percent of the total cost on an indemnity plan, leaving the patient to pay the remaining costs as a form of co-insurance.

  • Health Maintenance Organizations (HMOs)

 An organization that is able to provide urgent medical care directly to the insured is known as an HMO. The policy dictates its own choice of dedicated primary health care physician. It is this doctor’s responsibility to coordinate with the patent and the HMO for all necessary details.

As a general rule the HMO will fund only those treatments that are referred by their own GPs. They will be paying them pre-negotiated fees for every medical service that is undertaken in order to minimize costs. This is the least expensive form of health insurance in Kissimmee FL.

  • Conclusion

These are only a few types of health insurance policies in Kissimmee FL. What kind of insurance policy as well as payment option works best for you is a highly subjective decision. However, timely distribution of funds is of supreme importance so that your treatment remains uninterrupted. And you have to be very careful to only select an insurance agency that already has a great track record in disbursing payments. 


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