To cope with the potentially high costs of medical care, insurance policies provide some financial protection. Many individuals with insurance are covered under an employer-based plan (options offered and partially funded by their employer). Individual health insurance coverage, though more costly, can be obtained through some companies. Uninsured persons depend on their own ability to pay, qualifying for government insurance, or the care that physicians and institutions donate to those unable to pay. The March 14, 2007, issue of JAMA is a theme issue on access to health care.
Indemnity insurance covers some health expenses (usually at a set percentage of the charge) and allows an individual to select a physician or a hospital without restrictions. Patients are responsible for paying the portion of the medical bill that is not covered by insurance. This type of coverage has become uncommon.
Health maintenance organizations (HMOs) provide insurance coverage, usually through a lower-cost, employer-based plan. HMOs rely on a primary care physician to coordinate a person's care. There are restrictions on choice of physician, hospital, and other ancillary services. For specialty care to be covered, referrals to specialists must come from the primary care doctor. Procedures and tests must have preapproval from the HMO to be covered under the plan.
Preferred provider organizations (PPOs) are networks of physicians and institutions that work with a specific insurance company. Members of the network provide care at a negotiated rate to persons insured under the plan. In order to receive coverage in a PPO plan, your physician (both primary care and specialty physicians) must belong to the PPO network. If you choose a doctor or hospital that is not on the PPO plan (also called out-of-network), you will be responsible for some or all of the payment.
Government insurance, such as Medicare and Medicaid, is available to certain individuals under specific circumstances. Medicare is the health care plan for US citizens aged 65 years or older, persons with disabilities, and those with chronic renal failure. Most individuals need secondary insurance coverage to help with expenses not covered by Medicare. Recently, Medicare has developed prescription drug coverage to assist senior citizens with the cost of prescribed medications. Medicaid is health insurance for persons with very low incomes and for the disabled (if they do not qualify for Medicare). There are strict criteria for Medicaid qualification in each state.
It is important to read your policy thoroughly and understand what is covered. Since you will be responsible for paying medical bills that are denied by the insurance company, you should be familiar with what your policy actually does or does not cover.
Medical necessity refers to a determination that a treatment, test, or procedure is necessary to a person's health or to treat a diagnosed medical problem. Cosmetic procedures, for instance, are not covered under medical necessity provisions.
Co-payment is a specified dollar amount that the patient must pay to the physician or institution each time a service or visit is requested. Co-payments are usually required at the time of service and are set by the insurance company (typically an HMO or a PPO) as part of the policy.
Preexisting conditions are medical problems that an individual already has when he or she acquires an insurance policy. Preexisting conditions may not be covered by insurance policies.
Medical savings accounts (MSAs) allow persons to save money (often on a pretax basis) from their paycheck to be used for health care expenses. These expenses can include deductible amounts, co-payments, uncovered medical expenses (glasses, dental care, prescription medications), or expenses above the policy limits.
Centers for Medicare & Medicaid Services 877/267-2323 http://www.cms.govhttp://www.medicare.gov
National Mental Health Information Center 800/789-2647 http://www.mentalhealth.samhsa.gov
To find this and previous JAMA Patient Pages, go to the Patient Page Index on JAMA's Web site at http://www.jama.com. Many are available in English and Spanish.
Sources: US Department of Labor; National Institutes of Health; National Mental Health Information Center
The JAMA Patient Page is a public service of JAMA. The information and recommendations appearing on this page are appropriate in most instances, but they are not a substitute for medical diagnosis. For specific information concerning your personal medical condition, JAMA suggests that you consult your physician. This page may be photocopied noncommercially by physicians and other health care professionals to share with patients. To purchase bulk reprints, call 203/259-8724.
TOPIC: ACCESS TO CARE
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Comments are moderated and will appear on the site at the discretion of the Journal of American Medical Association editors. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Register Now
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.