American medical insurance system?

First, the American medical insurance system.

The rapid development of American medicine has attracted worldwide attention, but it is not easy to make new medical achievements available to all patients. Without medical insurance, the monthly income of an ordinary worker is often only enough to pay for one day's hospitalization, not to mention using expensive new drugs. If you don't choose the right medical insurance, once you get seriously ill, the medical expenses will also ruin you. People who apply for medical insurance will get a medical insurance card, and the hospital will settle accounts with relevant insurance companies according to this card and number.

II. Introduction

There are many kinds of medical insurance in the United States, which often confuses first-time applicants. There are student medical insurance for students and unlimited private insurance for the rich. American medical insurance system The coverage of federal medical insurance is also very extensive, including "medical care" insurance for the elderly and the disabled over 65, and "medical care for the poor" plan for low-income families. In the United States, rich people can have more than one private doctor, and the cost of seeing a doctor anywhere in the world is "reimbursed", provided that they pay expensive insurance premiums every month. The poor can only find medical insurance institutions with lower insurance premiums and go to designated hospitals for treatment. People who can't make ends meet may not participate in any medical insurance. Once they have to see a doctor because of illness, they can queue up in public hospitals and fill out lengthy and cumbersome declaration forms to get free prescriptions.

Third, various medical profiles

1、GHI

GHI is a popular medical insurance in new york, New Jersey and Connecticut. Founded in 1937, it has covered the west coast. This is a self-proclaimed non-profit insurance plan. 1995 The number of participants is about 2.7 million. About 13500 medical experts joined. Although this is a non-profit insurance company, the premium received by 1995 reached1300 million dollars. One of the advantages of GHI is that the insured can choose their own personal doctor. This is very important for many immigrants. Many people in China are not fluent in English, so it is common to choose a doctor in China. Patients only need to pay a fixed fee of five yuan for each visit, and the rest will be borne by the insurance company.

But this does not mean that doctors can charge and prescribe at will according to patients' requirements. GHI insurance system requires doctors to join the plan, that is, be bound by it. There are strict regulations on what kind of prescription to prescribe and what kind of treatment to take, and there is also an upper limit on the final treatment cost. The extra insurance company will not bear 1 cent.

Another way of insurance is that the medical expenses within a certain range need to be borne by the patients themselves. This part of the money is called automatic deduction, and the excess is borne by the insurance company. Some even ask patients to pay some insurance premiums.

Reducing waste and improving efficiency are the goals of various insurance plans. Because most emergencies can be reimbursed, insurance companies have strict definitions of emergencies: how many degrees of fever and whether the trauma is sutured are the criteria for identification. Insurance companies also have strict regulations on the payment of hospitalization fees, medicine fees, medical equipment fees, laboratory fees and X-ray fees.

Some insurances also stipulate the number of days of hospitalization allowed each year, usually between 60 days and 100 days, and some insurance companies will no longer pay the bill. Insurance companies and related experts work together to formulate standards, what kind of diseases, and what the longest hospitalization time should be; How long it takes to transfer to a rehabilitation hospital is stipulated.

2. Medical savings account

Medical savings account is another new type of insurance that the United States just started to try out last year. As soon as it was launched, it was welcomed by many low-and middle-income people.

Participants in the program set up a special personal account in the bank, and only need to deposit $65,438+038 every month, and can set up a program that pays less than $2,250. The family insurance premium is $4,365,438 +0, and the annual medical expenses of the whole family exceed $4,500, which shall be borne by the insurance company. The expenses of seeing a general dentist, vision correction and psychologist can also be reimbursed. At present, the general medical insurance, personal monthly insurance premium of at least $200. In addition, ordinary medical insurance, even if you don't see a doctor or stay in hospital, you can't get it back after paying the premium.

The characteristic of medical savings account is that individuals only need to put 65% of their out-of-pocket expenses in each year, and families only need to put 75% of their out-of-pocket expenses in the bank, which needs to be deducted from this account when they are hospitalized. When they don't see a doctor, money is naturally placed in the bank like a demand deposit, which not only has interest, but also doesn't have to pay taxes.

But this year, the United States only accepted 750,000 households, which is still a drop in the bucket. At present, only one bank has opened this account and two insurance companies accept this kind of medical insurance.

3. Health care plan

A statistic shows that even if there is a "medical care" plan for the elderly, with the increase of diseases, the elderly will still spend more than 20% of their average income on medical expenses. The "medical care" plan is first used for operation. Clinton proposed a plan to cut $270 billion in seven years, which was opposed by many people, and then proposed a plan to cut $654.38+00 billion in five years. On the other hand, Republicans propose to hand over more health insurance for the elderly to private organizations. Therefore, more and more elderly people are worried about the quality of medical services.

The federal medical insurance plan "medical care" also has strict restrictions on hospitalization. First of all, there must be a doctor's certificate that the patient needs hospitalization or nursing. Secondly, the hospital where you live must participate in the federal medical insurance plan. Then it is approved by the utility evaluation Committee UPC of the hospital or the hospital re-evaluation agency PRO.

Usually, participants should also prepare a "pre-explanation" to tell the hospital what kind of services you want and what kind of services you don't want, because some services will bear their own expenses. The role of "pre-guidance" is to provide doctors with reference when patients lose their communication ability in medical emergencies.

4. Blue Cross and Blue Shield

For the elderly, it is more important to find a suitable insurance. But "medical care" or "medical care for the poor" provided by the government cannot be included. But the premium of these supplementary insurance types alone is as high as $65,438+0,000 per year.

"Imperial Blue Cross Blue Shield" is an insurance plan with many years of history under the American Blue Cross Blue Shield Association, and it is also an ideal insurance to help the elderly. It is very famous in new york area. It seems that there are many benefits: patients don't have to pay "out of pocket" by themselves, as long as they have medical needs, they will bear 100% of the hospitalization expenses, and the length of hospitalization is not limited; Only $10 is required for each visit; The examination fee is free; 24 hours telephone consultation service. The most attractive thing is that emergency treatment is reimbursed anywhere in the world.

Its "contracted hospitals" include many large hospitals such as new york Medical Center. Older people over 60 can join, but one of the conditions is that they need to join the "medical care" plan first.

5. Medical and health institutions have been gradually improved.

Health Insurance Organization (HMO), which appeared in the United States in recent years, is another medical insurance management model, which is highly respected by the federal government and accepted by more and more low-and middle-income people. At present,160,000 Americans have joined the program.

Health insurance organizations are not specific organizations, but the main types of medical management. It is composed of designated hospitals, insurance companies and government agencies, and the insured has corresponding fixed "attending doctors". Unless the doctor agrees, you must go to the designated hospital in the network. In this way, people who want to find more experts to treat diseases will feel too constrained. In addition, the premium provided by the government to HMO also tends to be compressed, so health care organizations are worried that services will "shrink" and patients will be lost.

The fixed-point service (POS) plan is a typical improved HMO medical service form. Participants can go anywhere and see any doctor as long as they pay 10% to 15% of the premium and about 30% of the medical expenses. Among the 630 HMO institutions in China, the implementation rate of such plans has increased from 20% in 1990 to 50%.

6. Oxford medical insurance

Oxford Medical Insurance Company, founded in 1984, is a very successful company of its kind in the eastern United States. 1996, Fortune magazine listed the fastest growing companies in the United States, ranking fifth. There are more than 37,000 doctors and nearly 2 million members in the company's network, including about 30,000 members from China who have developed in recent three years.

The company has put forward various schemes to allow the insured and their families to freely choose the services of any doctor or medical institution inside or outside the network. The difference is that members usually only pay $5 ~ 10 for online medical registration. To see a doctor outside the network, the first 200 yuan must be paid by the members themselves, that is, the "self-paid" part. The excess part is shared with the company in a certain proportion.

The Oxford preferential insurance scheme for the elderly is also a special insurance for the elderly over 65. According to the government's "medical care" plan, patients have to pay 20% of all hospitalization expenses on the first day of hospitalization, and the government pays 80%. Older people who are members of Oxford do not need to increase their premiums if they join the Oxford preferential plan again. But all the above hospitalization expenses can be avoided.

The company also underwrites emergency medical expenses for the elderly all over the world. If you don't need to be hospitalized, you only need to pay a fixed emergency fee of $50.

For more and more small businesses, the company also provides group insurance plans, and a company only needs three employees to join. In addition, the company's customer service center regularly holds health talks for the community, which is very popular among the elderly.

The soaring medical expenses in the United States have forced the federal government to find ways to reduce government investment. At present, the national expenditure on various medical expenses has increased from 654.38+072.6 billion dollars 20 years ago to 900 billion dollars at present. Among them, the government's medical plan is insufficient 1/3.

However, under this system, 40 million people are still excluded from the medical insurance plan, including at least 3 million children. When government investment is insufficient, it is natural for private institutions to intervene. From various forms of medical insurance, we can also see the fierce competition in American insurance industry.