Instruct: Given a question, retrieve passages that can help answer the question.
Query: Do you need to pay a deductible before insurance pays?
In terms of using such a plan, unlike an HMO plan, which has a copayment cost share feature (a nominal payment generally paid at the time of service), a PPO generally does not have a copayment but offers a deductible and a coinsurance feature. The deductible must be paid in full before any benefits are provided. After the deductible is met, the coinsurance benefits apply. If the PPO plan is an 80% coinsurance plan with a $1,000 deductible, the patient pays 100% of the allowed provider fee up to $1,000. The insurer will pay 80% of the other fees, and the patient will pay the remaining 20%. Charges above the allowed amount are not payable by the patient or insurer but written off as a discount by the physician.
Canada (with the exception of the province of Quebec) is one of the few countries with a universal healthcare system that does not include coverage of prescription medication (other such countries are Russia and some of the former USSR republics even though Russia is considering a switch to full coverage of many prescription medications in the near future). Residents of Quebec who are covered by the province's public prescription drug plan pay an annual premium of $0 to $660 when they file their Quebec income tax return. Pharmaceutical medications are covered by public funds in some provinces for the elderly or indigent, or through employment-based private insurance or paid for out-of-pocket. Most drug prices are negotiated with suppliers by each provincial government to control costs but more recently, the Council of the Federation announced an initiative for select provinces to work together to create a larger buying block for more leverage to control costs of pharmaceutical drugs. More than 60 percent of prescription medications are paid for privately in Canada. Family physicians (often known as general practitioners or GPs in Canada) are chosen by individuals. If a patient wishes to see a specialist or is counselled to see a specialist by their GP, a referral is made by a GP in the local community. Preventive care and early detection are considered critical and yearly checkups are recommended for everyone.
As with all HMOs—no matter whether a person is on Medicare or not—persons who enroll in a Medicare Advantage or other Part C HMO cannot use certain specialist physicians or out-of-network providers without prior authorization from the HMO, except in emergencies. In almost all Medicare Advantage plans—HMO or otherwise—the beneficiary must choose a primary care physician (PCP) to provide referrals and the beneficiary must confirm that the plan authorizes the visit to which the beneficiary was referred by the PCP. As with all HMOs, this can be a problem for people who want to use out-of -network specialists or who are hospitalized and are forced to use out-of-network doctors while hospitalized. Many Medicare Advantage PPO plans permit a subscriber to use any physician or hospital without prior authorization, but at a somewhat higher expense.
A preferred provider organization is a subscription-based medical care arrangement. A membership allows a substantial discount below the regularly charged rates of the designated professionals partnered with the organization. Preferred provider organizations themselves earn money by charging an access fee to the insurance company for the use of their network (unlike the usual insurance with premiums and corresponding payments paid either in full or partially by the insurance provider to the medical doctor). They negotiate with providers to set fee schedules, and handle disputes between insurers and providers. PPOs can also contract with one another to strengthen their position in certain geographic areas without forming new relationships directly with providers. This will be mutually beneficial in theory, as be billed at a reduced rate when its insureds utilize the services of the "preferred" provider and the provider will see an increase in its business as almost all insureds in the organization will use only providers who are members. PPOs have gained popularity because, although they tend to have slightly higher premiums than HMOs and other more restrictive plans, they offer patients more flexibility overall.
From 2000 a universal health coverage has been in place, providing two fundamental rights for access to care: a right to health insurance for anyone in stable and regular residence in the territory and a right for the most disadvantaged, submitted to resources, to a free coverage, with exemption from fee.
On September 24, the CBO re-evaluated the proposal, taking into account the changes created by the Senate Committee. The CBO stated that the proposal would bring in $23 billion in the first ten years. Specifically, the Committee decreased the penalties for avoiding buying insurance, expanded the subsidies, and lowered the excise tax on high end insurance plans. A CBO report issued on October 7 stated that enacting the proposal would, on net, end up reducing the federal deficit by $81 billion over the 2010–2019 period. That report prompted praise from White House Press Secretary Robert Gibbs and from Senate Majority Leader Harry Reid, Dem. from Nevada, who called the scoring a "landmark occasion". Senate Minority Leader Mitch McConnell, Rep. from Kentucky, criticized the numbers as misleading given that the Baucus proposal would not come into effect for about another five years.
In health insurance in the United States, a preferred provider organization (PPO), sometimes referred to as a participating provider organization or preferred provider option, is a managed care organization of medical doctors, hospitals, and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.
The first move towards a national health insurance system was launched in Germany in 1883, with the Sickness Insurance Law. Industrial employers were mandated to provide injury and illness insurance for their low-wage workers, and the system was funded and administered by employees and employers through "sick funds", which were drawn from deductions in workers' wages and from employers' contributions. Other countries soon began to follow suit. In the United Kingdom, the National Insurance Act 1911 provided coverage for primary care (but not specialist or hospital care) for wage earners, covering about one third of the population. The Russian Empire established a similar system in 1912, and other industrialized countries began following suit. By the 1930s, similar systems existed in virtually all of Western and Central Europe. Japan introduced an employee health insurance law in 1927, expanding further upon it in 1935 and 1940. Following the Russian Revolution of 1917, the Soviet Union established a fully public and centralized health care system in 1920. However, it was not a truly universal system at that point, as rural residents were not covered.
The Sun 1,447,959 -7%
According to Canada's constitution, the provinces have responsibility for health care, education and welfare. However, the federal Canada Health Act sets standards for all the provinces. The Canada Health Act requires coverage for all medically necessary care provided in hospitals or by physicians; this explicitly includes diagnostic, treatment and preventive services. Coverage is universal for qualifying Canadian residents, regardless of income level.
One of the most prominent features of the FEHB program is the choices it allows. There are three broad types of plans: fee-for-service and preferred provider organization (PPO), usually offered in combination; HMOs; and high-deductible health plans and other consumer-driven plans. In the Washington, D.C., metropolitan area, plans open to all federal employees and annuitants include 10 fee-for-service and PPO plans, seven HMOs, and eight high-deductible and consumer-driven plans. A similar number of choices is offered in almost all large metropolitan areas, and in many smaller cities and rural areas. The program is sometimes criticized for offering this broad array of choices, but there are many ways enrollees can obtain advice and assistance, including advice from office colleagues and friends, newspaper and magazine articles in both the general press and publications that specialize in federal employees or retirees, OPM publications and Web site, and several online tools that compare plans' costs, benefits, and services. As a noticeably consumer-friendly service, OPM requires that all plans publish brochures that describe benefits in plain English and in a standardized format that facilitates plan comparison and that can easily be downloaded in PDF format. Almost all plans provide Web sites that provide detailed information not only on their benefits, but also on their provider panels and their drug formularies. There is no published evidence that either in the FEHB program or in the other two federal programs that offer a wide range of plan choices, the Medicare Advantage and Medicare Prescription Drug programs, consumer confusion is a serious problem, or that health insurance choices are any more complicated to deal with than other consumer choices among complex products or services, such as choices as to automobile purchase or service, choice among physicians, or choice among life insurance and other insurance products. One study found that on the whole Medicare beneficiaries, who are both elderly and far less educated than the population at large, nonetheless were able to substantially reduce their drug costs by choosing, albeit imperfectly, Medicare prescription drug plans that reduced their drug costs from what would have been considerably higher costs. A recent evaluation of the FEHB program found that Open Season movement reduces premiums on average by about 1 percent compared to prior enrollment patterns, despite the tendency of enrollees to remain in current plans without considering alternative choices.
Group C
Though the Commonwealth government has its own tax laws, Puerto Ricans are also required to pay many kinds of U.S. federal taxes, not including the federal personal income tax for Puerto Rico-sourced income, but only under certain circumstances. In 2009, Puerto Rico paid into the U.S. Treasury. Residents of Puerto Rico pay into Social Security, and are thus eligible for Social Security benefits upon retirement. They are excluded from the Supplemental Security Income (SSI), and the island actually receives a smaller fraction of the Medicaid funding it would receive if it were a U.S. state. Also, Medicare providers receive less-than-full state-like reimbursements for services rendered to beneficiaries in Puerto Rico, even though the latter paid fully into the system.
A generic drug is a chemically equivalent, cheaper version of a brand-name drug. A generic drug form is required to have the same dose, strength and active ingredient(s) as the brand name drug; thus, they carry the same risks and benefits. To ensure compliance, the FDA Generic Drugs Program conducts stringent reviews (3,500 inspections of manufacturing plants per year). Although generic drugs sound like a great money-saver, generic medicines can only be sold after the patents of the brand name versions end. Because of this mandatory period of exclusivity for many brand-name drugs (a period in which generic medicines cannot be sold), delay of generic drugs reaching the market is expected. The high cost of upfront research that the brand-name products have to go through to ensure safety and efficacy largely account for the high discrepancy in pricing between the two groups.
Group D
Health insurance in the Netherlands is mandatory. Healthcare in the Netherlands is covered by two statutory forms of insurance:
While Dutch residents are automatically insured by the government for Wlz, everyone has to take out their own basic healthcare insurance (basisverzekering), except those under 18 who are automatically covered under their parents' premium. If you don't take out insurance, you risk a fine.
Insurers have to offer a universal package for everyone over the age of 18 years, regardless of age or state of health – in most cases it's illegal to refuse an application or impose special conditions, but not always.
In contrast to many other European systems, the Dutch government is responsible for the accessibility and quality of the healthcare system in the Netherlands, but not in charge of its management.
Medicare () is an unofficial designation used to refer to the publicly funded, single-payer health care system of Canada. Canada does not have a unified national health care system; instead, the system consists of 13 provincial and territorial health insurance plans that provides universal health care coverage to Canadian citizens, permanent residents, and certain temporary residents. These systems are individually administered on a provincial or territorial basis, within guidelines set by the federal government. The formal terminology for the insurance system is provided by the "Canada Health Act" and the health insurance legislation of the individual provinces and territories.
Today, this system is more or less intact. All citizens and legal foreign residents of France are covered by one of these mandatory programs, which continue to be funded by worker participation. However, since 1945, a number of major changes have been introduced. Firstly, the different health care funds (there are five: General, Independent, Agricultural, Student, Public Servants) now all reimburse at the same rate. Secondly, since 2000, the government now provides health care to those who are not covered by a mandatory regime (those who have never worked and who are not students, meaning the very rich or the very poor). This regime, unlike the worker-financed ones, is financed via general taxation and reimburses at a higher rate than the profession-based system for those who cannot afford to make up the difference. Finally, to counter the rise in health care costs, the government has installed two plans, (in 2004 and 2006), which require insured people to declare a referring doctor in order to be fully reimbursed for specialist visits, and which installed a mandatory co-pay of €1 for a doctor visit, €0.50 for each box of medicine prescribed, and a fee of €16–18 per day for hospital stays and for expensive procedures.
A 2008 article in the journal "Health Affairs" suggested that the Dutch health system, which combines mandatory universal coverage with competing private health plans, could serve as a model for reform in the US. However,
an assessment of the 2006 Dutch health insurance reforms published in Duke University's "Journal of Health Politics, Policy and Law" in 2008 raised concerns. The analysis found that market-based competition in healthcare may not have the advantages over more publicly based single payer models that were originally envisioned for the reforms:
The National Insurance number is used as a reference number in the Pay As You Earn system, and also by the self-employed. It is also used in applications for Individual Savings Accounts (ISAs), to check that an individual has opened only one ISA in a tax year.
The preliminary determination directs U.S. Customs and Border Protection to require cash deposits for the duties on all new imports as well as softwood products imported over the past 90 days. To remain in effect, however, the duties need to be finalized by Commerce and then confirmed by the U.S. International Trade Commission after an investigation that includes testimony from both sides. In response, the Canadian federal government indicated that it was exploring the possibility of banning United States coal from being exported through Canadian ports and imposing a retaliatory tariff on lumber exports from Oregon.
Since the majority (85%) of Americans have health insurance, they do not directly pay for medical services. Insurance companies, as payors, negotiate health care pricing with providers on behalf of the insured. Hospitals, doctors, and other medical providers have traditionally disclosed their fee schedules only to insurance companies and other institutional payors, and not to individual patients. Uninsured individuals are expected to pay directly for services, but since they lack access to pricing information, price-based competition may be reduced. The introduction of high-deductible insurance has increased demand for pricing information among consumers. As high-deductible health plans rise across the country, with many individuals having deductibles of $2500 or more, their ability to pay for costly procedures diminishes, and hospitals end up covering the cost of patients care. Many health systems are putting in place price transparency initiatives and payments plans for their patients so that the patients better understand what the estimated cost of their care is, and how they can afford to pay for their care over time.
The second is excess-pre-hospitalization which refers to an insurance exception that is (often interchangeably but wrongly) referred to also as an excess or a deductible. It is "the first amount of the claim which the insured has to bear. If the insured has an excess of $500 and the total repair costs $3,000, then the insured has to pay $500 while the insurer pays the remaining $2,500."
Most policies have an elimination period or waiting period similar to a deductible. This is the period of time that you pay for care before your benefits are paid. Elimination days may be from 30 to 120 days after a long-term care incident, such as a fall or illness. Some policies require intended claimants to provide proof of 30 to 120 service days of paid care before any benefits will be paid. In some cases, the option may be available to select zero elimination days when covered services are provided in the home in accordance with a Plan of Care.
Interest incurred on indebtedness has historically been deductible, (although the deduction of "personal" interest was largely eliminated in 1986), and in the 1950s a type of "leveraged insurance" transaction began being marketed that permitted an insurance owner to in effect deduct the cost of paying for insurance by (1) paying large premiums to create cash values, (2) "borrowing" against the cash value to in effect strip out the large premiums, and (3) paying deductible "interest" back to the insurer, which was in turn credited to the policy's cash value as tax-deferred earnings on the policy that could fund the insurer's legitimate charges against policy value for cost of insurance, etc.