(US specific) Provided by an employer-sponsored self-funded ERISA plan. The company generally advertises that they have one of the big insurance companies. However, in an ERISA case, that insurance company "doesn't engage in the act of insurance", they just administer it. Therefore, ERISA plans are not subject to state laws. ERISA plans are governed by federal law under the jurisdiction of the US Department of Labor (USDOL). The specific benefits or coverage details are found in the Summary Plan Description (SPD). An appeal must go through the insurance company, then to the Employer's Plan Fiduciary. If still required, the Fiduciary's decision can be brought to the USDOL to review for ERISA compliance, and then file a lawsuit in federal court.
Although the elimination of the individual mandate penalty and the expansion of short-term plans and association health plans are serving to drive premiums higher than they would otherwise have been in 2019, there are other factors, particularly when we look at rates on a state-by-state basis, that are causing rates to be lower than they would otherwise have been.
The management and administration of health care is vital to the delivery of health care services. In particular, the practice of health professionals and operation of health care institutions is typically regulated by national or state/provincial authorities through appropriate regulatory bodies for purposes of quality assurance.[25] Most countries have credentialing staff in regulatory boards or health departments who document the certification or licensing of health workers and their work history.[26]
There are new insurers joining the exchanges in many states, and the slight decrease in benchmark premiums means that your after-subsidy premium might be higher than it was in 2018 if you just keep your current plan. Switching to a lower-cost plan might be an option for many enrollees, although there's not a one-size-fits-all answer there either, since it will depend on the provider network, overall benefits, and covered drug lists for the alternative plans you're considering.
Then the choice is clear: You need an ACA plan. ACA plans are the only option that will cover all pre-existing conditions on day 1 without waiting periods. Same with prescriptions. If you have lots of prescriptions you need coverage for then an ACA plan is your best option. Most alternative healthcare options will give you discounts on prescriptions but will not give you a “copay” structure like ACA plans—although many ACA plans do subject you to your plan deductible first. Some ACA alternatives will cover pre-existing conditions after a 12-24 month waiting period.
It is well recognized that the physical environment is important for the well-being of people with dementia. This influences developments within the nursing home care sector where there is an increasing interest in supporting person-centered care by using the physical environment. Innovations in nursing home design often focus on small-scale and homelike care environments. This study investigated: (1) the physical environment of different types of nursing homes, comparing traditional nursing homes with small-scale living facilities and green care farms; and (2) how the physical environment was being used in practice in terms of the location, engagement and social interaction of residents. Two observational studies were carried out. Results indicate that the physical environment of small-scale living facilities for people with dementia has the potential to be beneficial for resident’s daily life. However, having a potentially beneficial physical environment did not automatically lead to an optimal use of this environment, as some areas of a nursing home (e.g., outdoor areas) were not utilized. This study emphasizes the importance of nursing staff that provides residents with meaningful activities and stimulates residents to be active and use the physical environment to its full extent. Full article
When you purchase coverage during open enrollment, the effective date will be January 1, 2019. If you already have an individual market plan and you’re picking a different one during open enrollment, your current plan will end on December 31 (assuming you continue to pay all of your premiums when they’re due) and the new plan will take effect seamlessly the following day.
In 2006, a new system of health insurance came into force in the Netherlands. This new system avoids the two pitfalls of adverse selection and moral hazard associated with traditional forms of health insurance by using a combination of regulation and an insurance equalization pool. Moral hazard is avoided by mandating that insurance companies provide at least one policy which meets a government set minimum standard level of coverage, and all adult residents are obliged by law to purchase this coverage from an insurance company of their choice. All insurance companies receive funds from the equalization pool to help cover the cost of this government-mandated coverage. This pool is run by a regulator which collects salary-based contributions from employers, which make up about 50% of all health care funding, and funding from the government to cover people who cannot afford health care, which makes up an additional 5%.[31]
Over the last few years, there has been considerable public concern (and plenty of outcry from critics) about “narrow networks” — provider networks that have been downsized by insurance carriers as they attempt to control their bottom lines. And it is true that narrower networks could mean that your doctor or your health care facility might no longer be on your current plan’s network for the coming year
This has been very controversial. On one hand, people in that situation (i.e., having to pay full price for a health insurance policy in the individual market, which can easily cost 20+ percent of a person's income if they're just a little over the income limit for subsidy eligibility) are desperate for lower-cost alternatives. And if they're healthy, they may very well be willing to take a gamble and settle for a less robust plan that's easier to fit into their budget.
Background: Craniosynostoses are congenital defects in the construction of the skull involving premature fusion of one or more cranial sutures. Premature fusion of sutures causes characteristic skull deformation(s). This affect the structure and thus the appearance of the entire head and face. The aim of this study was to analyze parents’ subjective assessments of head and facial appearance in children with craniosynostoses before and after surgery. Parents also assessed the interpersonal relationship of their children with peers and adults (after surgery). Methods: This study was conducted among parents of 230 children treated in Poland, in two multidisciplinary centers. Detailed statistical analysis was conducted among children who had undergone surgery. Independent variables were age (at survey) of the child (three years and less, four years, and five years and more) and type of craniosynostosis (isolated and syndromic). A chi-square independence test was used. Data was collected using surveys. Results: In the opinion of most parents, the appearance of their child’s head and face after surgery did not differ or differed only slightly from that of their peers. The results of subjective assessment of appearance of children’s face and head after reconstructive treatment remains comparable in three subgroups of patients according to the age. It seems that specific head shape according to the type of craniosynostosis does not have an impact on relations with peers and adults. Conclusion: Surgical treatment of children with craniosynostoses improves the appearance of their head and face. This improvement seems not to depend on the type of isolated craniosynostosis, and is constant over time. Full article
Out-of-pocket maxima: Similar to coverage limits, except that in this case, the insured person's payment obligation ends when they reach the out-of-pocket maximum, and health insurance pays all further covered costs. Out-of-pocket maxima can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.
We would be willing to take on a significantly higher deductible in a catastrophic plan. Even $20 – $25k a year deductible in order to keep basic premiums low and pay for most things out of pocket. Depending on the landscape when we retire (whether subsidies still exist), we could COBRA until the end of that year and shop for a low premium plan for the following year. And like the good ole doc, we are beefing up our HSA accounts while we can to fill in gaps if we need to until becoming eligible for Medicare. Hoping to preserve them for later on though.

 There are other HCSM plans out there. We personally used a different popular “liberty-based” HCSM for 3 years but had a horrible time getting claims paid when we needed it in the 3rd year. Therefore, based on our own experience, we do not recommend the other ‘liberty-based’ HCSM plan. However, we understand our experience may be anecdotal and others may be happy with an alternative.
Many consumers face unaffordable premiums – perhaps because they’re in the coverage gap or because their incomes make them ineligible for subsidies. Even consumers planning to buy an ACA-compliant plan during open enrollment may have to wait up to two months for the new plan to take effect. If they’re currently uninsured, a short-term plan can bridge that gap.
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