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Medical insurance policies are of four basic types with respect to contracting for them, as contrasted with kinds of providers such as PPOs and HMOs. Each kind of insurance policy has significant ramifications for coverage, claims, and appeals, as well as costs. The basic types of policies are set forth below:
1. Private or government entity purchases a group policy for which it pays a premium and receives benefits for its employees and their families, known as beneficiaries.
2. Private or government entity purchase a group policy for which it pays for administrative functions; but instead of paying premiums for coverage, is self-insured (i.e., the entity provides the benefits; not the insurancecompany).
3. Private or government entity purchases a policy for which it pays a premiumand independent contractors join and they and their families receive benefits.
4. Family or person purchases a policy for which it receives a premium and the the family members receive benefits.
The cost of the insurance policy is negotiated between the private or government entity, a family or a person. The cost is based on options including, but not limited to: the medical facilities; physicians; surgeons; allied medical professionals; drugs, products, and services provided and covered by the insurance company, both locally, and out-of-networkselected; and the political and financial environment within the insurance industry.
The insurance policy is generally implemented with (1) a handbook for the beneficaries; (2) a schedule of benefits; (3) policies and bulletins relating to specific critrera for medical necessity and coverage; and (4) insurance policy riders and supplements or updates. Collectively those documents contain all covered, conditionally covered, and excluded drugs, products, and services, and service providers within the network of the insurance company and outside of its network; and, all policies and procedures relating to the insurance policy, which is a contract between the insurance company and the principal owner of the policy.
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