PharmX Universal Health Care Services (PUHCS) has long supported efforts to implement reforms that expand access to quality and affordable health care to our clients. Since the passage of the Affordable Care Act, we have sought to be thoroughly compliant with its requirements and to provide accurate, timely information about its implementation to our members and stakeholders of our company. We will continue to follow the law and look forward to working with members of Congress, the Administration and state governments on constructive ways to provide affordable, quality coverage to our members while ensuring a viable, competitive private sector marketplace.
Medicare is the United States' federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). In general, all persons 65 years of age or older who have been legal residents of the United States for at least 5 years are eligible for Medicare.
Before your 65th birthday is the time to start thinking about Medicare. That means understanding what Medicare is, how and when to enroll, and what it does and does not cover. The way you choose to receive your Medicare benefits affects many aspects of your coverage including out-of-pocket costs, plan benefits and provider networks.
If you are approaching age 65 and are not familiar with Medicare, the Centers for Medicare and Medicaid Services have established a website, Medicare.gov, which will answer some of your questions.
While Medicare is a federal program, private insurers can and do play a role in providing your health plan coverage. You can choose to receive all of your Medicare benefits through a private insurer, or you can choose to receive your Part A and B coverage through original Medicare and sign up for a Medicare Prescription Drug Plan (Part D) with a private insurer. Additionally, you can choose to add on to your Medicare coverage with a Medicare Supplement Insurance Plan, often referred to as Medigap, that helps you with the cost of copays, coinsurance and deductibles among other expenses.
How Health Insurance Works
Health care is expensive. Health care costs are increasing every year. Without health insurance it would be difficult for most people to afford their health care bills.
Health insurance is a way for people to:
There are two types of health insurance:
Taxpayer-funded health insurers are funded by state and federal taxes. Examples include:
Private health insurance is primarily funded through benefits plans provided by employers.
To receive health insurance, employees choose to participate in their employer-sponsored plan. They pay a premium. In return, they receive an insurance card that gives them access to the doctors, hospitals and other health care providers that are part of the insurance plan.
Health Insurance Regulations
Health insurance makes health care more affordable.
Health insurance helps people pay for health care by combining the risk of high health care costs across a large number of people, permitting them (or employers) to pay a premium based on the average cost of medical care for the group. Thus, health insurance makes the cost of health care affordable for most people.
Health insurance provides security.
When an individual has an insurance card, it provides easier access to medical care by showing health care providers that most of the individual’s covered treatment costs will be paid.
Employer-sponsored Health Insurance
Most private health insurance is provided through employer-sponsored benefits plans.
Employers decide …
Employees do this …
States generally regulate the business of health insurance. At the same time, a number of federal laws also govern health insurance. We will review two specific federal laws: ERISA and HIPAA.
States set standards covering when and on what terms a state-licensed health insurer must accept an applicant. For example, most states mandate that coverage must be given to small employers that want it. States mandate the extent to which insurers can vary premiums based on health status, claims experience and other factors.
However, states cannot require self-funded employer plans to offer benefits (these plans are governed under ERISA).
States have lists of mandated benefits. Some examples are:
Employee Retirement Income Security Act of 1974 (ERISA)
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA addresses the concern that:
HIPAA requires state-licensed private insurers to accept certain people leaving group health coverage into the individual market regardless of their health status and without any exclusion period for pre-existing medical conditions. However, in most states, if eligible people are guaranteed access to coverage in the state's high-risk pool, private insurers are not required to sell coverage to them.
HIPAA also prohibits state-licensed private insurers from considering the health status of a member when determining the member’s eligibility for group coverage.