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  • Writer's picturePhysical Therapy International Service

A Quick Look Into Health Insurance in America

By Rachel Luzer, Aiyannah Wilson, and Chiamaka Obidigbo



The United States utilizes components of every model which includes the single payer-governmental model, the national health insurance, universal insurance, and the out-of-pocket model. Most forms of medical insurance serve as a contract between an individual and an insurance company that take off significant health care costs away from the individual for a premium rate. Physical therapy services are typically financed through reimbursement from insurance companies. Services can become costly for the general patient as it usually requires regular appointments, multiple times a week (depending on the treatment plan), to revive a patient’s functionality. Despite there being other ways to pay for sessions such as self-pay, it is typically more affordable to use insurance. There are many kinds of health insurances such as medicaid, medicare, private, and community plans that cater to different populations at different costs. In the field of Physical Therapy, the physical therapist perform evaluations and based on their findings, insurance companies authorize a certain amount of visits. Some insurance plans limit the amount of visits for therapy per calendar year which may impact the plan of care.Additionally, therapists can request more visits when appropriate. In general, it is important to review this information with the clinic you want to schedule with for your physical therapy services and they will track insurance visits, limits, and other requests for their patient and plan accordingly.


Medicare:

Medicare is a type of public insurance. This insurance type is offered to individuals sixty-five years or older. In addition to children/adolescents with disabilities or individuals with End Stage Renal Disease (long-term kidney failure requiring dialysis or transplant). It offers two types, Part A Hospital Insurance and Part B Medical Insurance. Most people receive Part A if they were employed and contributed to Medicare taxes whereas Part B requires a monthly payment. Part A covers inpatient hospital care, skilled nursing facility, hospice (end of life care), lab tests, surgery, home health care, and some preventative services. Part B covers health providers’ services, outpatient care, medical equipment, home health care, and preventative services. Individuals who are interested in either form of Medicare should check their eligibility to better understand the different policies.


Medicaid:

Similar to Medicare, Medicaid is public insurance that provides health coverage for low-income families. Medicaid is accessible for children, parents, pregnant women, seniors, and individuals with disabilities. Every state follows its own medicaid program; individual eligibility varies based on the state. However, there are mandated rules that each state must cover. Eligibility includes children under age 18 in families and pregnant people below the 138% federal poverty line. Certain parents and caretakers with low income, and most seniors and people with a disability who receive Supplemental Security Income assistance.


Private Insurance:

In addition to government-sponsored health insurance, private insurance is also available. Private health insurance is typically sold to individuals through employment but can be purchased directly through individual. Private health insurance covers more than half of the U.S. population. Private insurance is regulated at both the state and federal level. Most employer-sponsored private health insurance plans meet the minimum essential coverage of the Affordable Care Act (ACA). The different types include short-term health, fixed indemnity, critical illness, accident supplements, dental and vision which are not qualified health plans under the ACA.


Community Plan Insurance:

A new type of insurance called Community Plan Insurance is similar to the Medicaid managed care program. It’s offered to people with physical disabilities who are eligible for both Medicaid and Medicare. The mission of the Community Plan is to coordinate physical health care with ongoing services and support. This insurance type increases healthcare access to individuals. This plan enhances healthcare services for thousands of individuals state by state in hopes to improve quality of life. Individuals who qualify for Community Plan Insurances, also known as Community Health Choices (CHC) are: those who qualify for Medicaid or Medicare and are twenty-one years and older. The present physical health benefits covered by Medicaid Adult Benefit Package will also be covered by CHC. Medicaid and prescription medication coverage are all included in one health plan under CHC.


Access to Insurance:

The main goal for most healthcare providers especially within the US is to provide time-efficient and high-quality healthcare services.Although, many Americans are unable to receive necessary health care services due to limited access. For example, About 1 in 10 people in the United States don’t have access to health insurance. (U.S Department of Health and Human Services) People without insurance may not be able to afford necessary medical care and prescriptions when they become sick. Additionally, they are less likely to have a primary care physician. Ensuring more individuals have access to quality health care services, such as preventative care and treatment for chronic illnesses requires developing strategies to increase access to insurance. There are a multitude of factors that lead to decreased access to quality medical services.


For example, if a person doesn’t have a primary care physician, they may not receive a cancer screening . More people can receive the care they need with strategies to improve communication and increase access to health care experts, whether in person or virtually. These are some new ways being implemented to help combat the lack of access to insurance.


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