美國醫(yī)療保險(xiǎn)英文演講人：日期：OverviewofUSHealthcareSystemTypesofHealthInsuranceinUSACoverageandBenefitsofUSHealthInsuranceCostsandFinancingofUSHealthInsuranceAccesstoCareunderUSHealthInsurance目錄01OverviewofUSHealthcareSystemHistoryandDevelopmentEarlyColonialEraHealthcarewasprimarilyprovidedbyfamiliesandcommunitieswithlimitedprofessionalmedicalcare19thCenturyTheriskofscientificmedicineandtheassessmentofmedicalschoolsandhospitals20thCenturyThedevelopmentofemployeebasedhealthinsuranceandgovernmentprogramssuchasMedicareandMedicaidRecentTrendsTheAffordableCareAct(ACA)andtheshiftrewardsvaluebasedcareandpatientcenteredoutcomesStructureandKeyPlayersPrivateHealthInsuranceCompaniesProvidecoveragetoindividualsandemployees,negotiatewithproviders,andmanageclaimsGovernmentHealthProgramsIncludeMedicareforolderadultsandMedicaidforlowincomeindividuals,amongothersHealthcareprovidersPhysicians,hospitals,hospitals,andotherhealthcarefacilitiesthatprovidemedicalservicesPatientsandConsumersIndividualswhoreceivemedicalcareandareresponsibleforunderstandingtheircoverageandmakinginformeddecisionsabouttheirhealthRegulatoryFrameworkMonitorandevaluatethequalityofhealthcareservicesprovidedbyprovidersandinsurersAccreditationandQualityImprovementOrganizationsOverseasnationalhealthpolicies,includingtheACA,andregulationsprivatehealthinsurancecompaniesFederalGovernmentRegularhealthinsurancemarketswithintheirborders,includingproviderlicensesandqualitystandardsStateGovernmentsRisingHealthcareCosts:AddressingtheunderlyingcausesofincreasinghealthcarespendingisakeychallengefortheUShealthcaresystemQualityandPatientSafety:ImprovingthequalityofcareandreducingmedicalerrorsisacriticalfocusareaforhealthcareprovidersandinsurersHealthDisparities:Addressinghealthdivisionsamongdifferentpopulations,suchasracialandethicalminorities,isanimportantgoalforthehealthcaresystemAccesstoCare:Ensuringthatallindividualshaveaccesstoaffordable,highqualityhealthcareservicesremainsasignificantissueChallengesandReforms02TypesofHealthInsuranceinUSAMedicalAfederalhealthinsuranceprogramforpeoplewhoare65orolder,certifiedyoungpeoplewithdisabilities,andpeoplewithEndStageRenalDiseaseMedicaidAjointfederalandstateprogramthathelpswithmedicalcostsforsomepeoplewithlimitedincomeandresourcesCHIP(Children'sHealthInsuranceProgram)AprogramthatprovideslowcosthealthcoveragetochildreninfamiliesthatearntoomuchmoneytoqualifyforMedicaidPublicHealthInsuranceProgramsPPO(PreferredProviderOrganization)AtypeofhealthplanthatcontractswithmedicalproviderstocreateanetworkofparticipatingprovidersMemberscanuseprovidersoutsidethenetworkforanadditionalcostHMO(HealthMaintenanceOrganization)AtypeofhealthinsuranceplanthatcommonlylimitscoveragetocarefromdoctorswhoworkfororcontractwiththeHMOEPO(ExclusiveProviderOrganization)SimilartoanHMO,anEPOtypicallydoesnotcoveroutofnetworkcareexceptinanemergencyHowever,anEPOdoesnotrequirememberstogetareferralforspecialistcarePrivateHealthInsurancePlansHealthinsuranceprovidedbyanemployeethatcoversemployeesandsomeoftheirdependenciesTheemployeetypicallypaysaportofthepremiumGroupHealthInsuranceAlsoknownasselfassuredplans,thesearehealthplanswheretheemployeebearstheriskforimprovinghealthcarebenefitstoitsemployeesTheemployeecontractswithathirdpartyadministratortoprocessclaimsandprovideotheradministrativeservicesSelfFundedHealthPlansEmployeeBasedHealthInsuranceMajorMedicalInsuranceAtypeofhealthinsuranceplanthatprovidescomprehensivecoverageforabroadrangeofhealthcareservices,includinghospitalization,physicalservices,andprescriptiondrugsShortTermHealthInsuranceAtemporaryhealthinsuranceplanthatprovidescoverageforalimitedperiodoftime,typicallybetween30daysand12monthsIndividualandFamilyHealthPlansCatastrophicHealthInsuranceAtypeofhighdeductiblehealthplanthatprovidescoverageonlyformajormedicalexpenses,suchashospitalizationandsurgeryHealthSavingsAccounts(HSAs)TaxadvancedsavingsaccountsthatcanbeusedtopayforqualifiedmedicalexpensesHSAsaretypicallypaidwithhighdeductiblehealthplansIndividualandFamilyHealthPlans03CoverageandBenefitsofUSHealthInsuranceHospitalCareIncludesinpatientandoutpatientservicesprovidedinahospitalsetting,suchassurgery,overnightstays,andemergencyroomvisitsPhysicalServicesCoversvisitstodoctors'offices,includingprimarycarephysiciansandspecialties,fordiagnosisandtreatmentofillessesorinjuriesDiagnosticTestingIncludeslaboratorytests,X-rays,MRIs,andotherdiagnosticproceduresorderedbyaphysiciantodiagnoseaconditionormonitortreatmentMedicalServicesCoveredGenericandBrandNameDrugsCoversthecostofsubscriptionmedicine,includingbothgenericandbrandnamedrugs,whensubscribedbyadoctorDrugFormulariesMosthealthinsuranceplanshavealistofcovereddrugs,knownasaformula,whichmaychangeperiodicallyPaymentsanddeductionsPatientsmayberesponsibleforapaymentordeductionforeachsubscriptionfilled,dependingontheplan010203PrescriptionDrugCoverageCoversregularvisitstoaprimarycarephysicianforpreventivecare,suchasannualphysicalandwellchildvisitsRoutineCheckupsIncludesimmunizationsrecommendedbytheCentersforDiseaseControlandPrevention(CDC)foradultsandchildrenVacanciesCoversscreensforcancerconditions,suchasdiabetes,highbloodpressure,andcancertypes,whenrecommendedbyadoctororhealthplanScreeningsPreventiveCareServices要點(diǎn)三CounselingandTherapyCoversvisitstomentalhealthprofessionals,suchaspsychologistsandpsychologists,fordiagnosisandtreatmentofmentalhealthconditions0102PatientandOutpatientTreatmentIncludestreatmentprovidedinahospitalorclinicsettingformoreseverementalhealthconditionsorsuspicionsduetoissuesMedicalManagementCoversthecostofprescriptionmedicineusedtotreatmentalhealthconditions,suchasantidepressantsandantipsychotics03MentalHealthandSubstanceAbuseTreatment04CostsandFinancingofUSHealthInsurancePremiumsTheamountpaidtotheinsurancecompany,typicallymonthly,forcoveragePremiumsarebasedonfactorssuchasage,location,andplantypeDeductiblesTheamountanindividualmustpayforhealthcareservicesbeforetheinsuranceplanstartstopayDeductiblescanvarysignificantlydependingontheplanPaymentsOncethedeductibleismet,theinsurancecompanytypicallypaysaportoftheremainingcosts,whiletheindividualpaystherest(knownascoinsurance)Premiums,Deductibles,andPaymentsOutofPocketMaximumsAlimitonhowmuchanindividualhastopayforhealthcareservicesinayearOncethislimitisreached,theinsuranceplanpays100%ofthecostsfortherestoftheyearOutofPocketMaximum(OOPM)DifferenthealthinsuranceplanshavedifferentOOPMs,soit'simportanttocompareplanscarefullyOOPMRisksbyPlanCostSharingReductions(CSR)Substancesprovidedtolowersomeindividualstohelpreducetheiroutofpocketcostsforhealthcareservices,suchasproducts,coinsurance,andpaymentsEligibilityforCSREligibilityforCSRisbasedonincomeandhouseholdsize,andistypicallyavailablethroughgovernmentfundedhealthinsurancemarketsCostSharingReductionsforLowIncomeIndividualsVSFinancialassistanceprovidedbythegovernmenttohelpindividualsafterhealthinsuranceThiscanincludesubsidiariesforpremium,products,andotheroutofpocketcostsTaxCreditsTaxbreaksorreductionsintaxableincomethatcanbeclaimedbyindividualswhopurchasehealthinsurancethroughagovernmentfundedmarketplaceTaxcreditsarebasedonfactorssuchasincomeandhouseholdsizeGovernmentSubjectsGovernmentSubjectsandTaxCredits05AccesstoCareunderUSHealthInsuranceProviderNetworksMosthealthinsuranceplansintheUShaveanetworkofhealthcareproviders,includingdoctors,hospitals,andothermedicalfacilities,thathaveagreedtoprovideservicestoplanmembersatdiscountedratesChoiceofDoctorsDependenceonthehealthinsuranceplan,membersmayhavethefreedomtochooseanydoctororberequiredtoselectfromalistofinnetworkprovidersSomeplansalsoofferoutofnetworkcoverage,butatahighercostProviderNetworksandChoiceofDoctorsEmergencyRoomVisitsHealthinsuranceplanstypicallycoveremergencyroomvisitsformedicalemergenciesHowever,it'simportanttonotethatsomeplansmayhavehigherpaymentsordeductionsforERvisits0102UrgentCareCentersFornonlifethreadingmedicalconditionsthatrequireimmediateattention,urgentcarecenterscanprovideaconservativeandcosteffectivealternative