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This is part of Understanding Health Insurance





Health Insurance is a Contract



What we call health insurance is a contract. When you get health insurance, you (or somebody on your behalf) are agreeing to a contract with a health insurance company – a contract where they agree to do certain things for you in exchange for money. So a health insurance plan is a contract between the insurance company and the customer (you).

For simplicity, I will use the term health plan to mean the actual contract – the specific health insurance product – you get from a health insurance company. (It sounds less weird than saying "an insurance" and is shorter to type than "a health insurance plan".)

One of the things this clarifies is that one health insurance company can have a bunch of different contracts (health plans) to sell. This is the same as how you may have more than one internet company that could sell you an internet connection to your home, and each of those internet companies might have several different package deals they offer with different prices and terms. In exactly that way, there are multiple different health insurance companies, and they each can sell multiple different health plans with different prices and terms.

Read more... [7,130 words] )

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Preface: I had hoped to get this out in a more timely manner, but was hindered by technical difficulties with my arms, which have now been resolved. This is a serial about health insurance in the US from the consumer's point of view, of potential use for people still dealing with open enrollment, which we are coming up on the end of imminently. For everyone else dealing with the US health insurance system, such as it is, perhaps it will be useful to you in the future.





Understanding Health Insurance:
Introduction



Health insurance in the US is hard to understand. It just is. If you find it confusing and bewildering, as well as infuriating, it's not just you.

I think that one of the reasons it's hard to understand has to do with how definitions work.

Part of the reason why health insurance is so confusing is all the insurance industry jargon that is used. Unfortunately, there's no way around that jargon. We all are stuck having to learn what all these strange terms mean. So helpful people try to explain that jargon. They try to help by giving definitions.

But definitions are like leaves: you need a trunk and some branches to hang them on, or they just swirl around in bewildering clouds and eventually settle in indecipherable piles.

There are several big ideas that provide the trunk and branches of understanding health insurance. If you have those ideas, the jargon becomes a lot easier to understand, and then insurance itself becomes a lot easier to understand.

So in this series, I am going to explain some of those big ideas, and then use them to explain how health insurance is organized.

This unorthodox introduction to health insurance is for beginners to health insurance in the US, and anyone who still feels like a beginner after bouncing off the bureaucratic nightmare that is our so-called health care system in the US. It's for anyone who is new to being an health insurance shopper in the US, or feels their understanding is uncertain. Maybe you just got your first job and are being asked to pick a health plan from several offered. Maybe you have always had insurance from an employer and are shopping on your state marketplace for the first time. Maybe you have always gotten insurance through your parents and spouse, and had no say in it, but do now. This introduction assumes you are coming in cold, a complete beginner knowing nothing about health insurance or what any of the health insurance industry jargon even is.

Please note! This series is mostly about commercial insurance products: the kinds that you buy with money. Included in that are the kind of health insurance people buy for themselves on the state ACA marketplaces and also the kind of health insurance people get from their employers as a "bene". It may (I am honestly not sure) also include Medicare Advantage plans.

The things this series explains do not necessarily also describe Medicaid or bare Medicare, or Tricare or any other government run insurance program, though if you are on such an insurance plan this may still be helpful to you. Typically government-run plans have fewer moving parts with fewer choices, so fewer jargon terms even matter to them. Similarly, this may be less useful for subsidized plans on the state ACA marketplaces. It depends on the state. Some states do things differently for differently subsidized plans.

But all these different kinds of government-provided health insurance still use some insurance industry jargon for commercial insurance, if only to tell you what they don't have or do. So this post may be useful to you because understanding how insurance typically works may still prove helpful in understanding what the government is up to. Understanding what the assumptions are of regular commercial insurance will hopefully clarify the terms even government plans use to describe themselves. Just realize that if you have a plan the government in some sense is running, things may be different – including maybe very different – for you.



On to the first important idea: Health Insurance is a Contract.



Understanding Health Insurance

busy week

Sunday, December 7th, 2025 05:20 pm[personal profile] mellowtigger
mellowtigger: (possum)

Monday after work, I did eventually walk to the store to buy some whisky. That strategy was good. I slept well that night.

Tuesday morning was a "snow day" at my remote job. I logged in for work and saw the notice that it was called off until noon due to local (in Pennsylvania) snow conditions. I also saw a coworker asking for someone to take his shift, because he needed to help a friend with a bad car situation. I (foolishly?) agreed, so I worked the skeleton crew to continue working on tickets that morning. It was another very busy day, though less busy than Monday.

Wednesday had more people on staff all day, but it was still a busier-than-usual Wednesday workload. I was glad when it was over, though, and my "weekend" began.

Thursday and Friday resulted in almost no accomplishments at all (well, some laundry), which was glorious.

Saturday morning, we had half of our crew out sick. And it was still a busier-than-usual day, so the few of us left were busy all day. On weekends, I usually have some free time to read Dreamwidth or the news, and I never opened the web browser that day.

Today, finally, full crew on staff and reasonable workload. "Normal" is such a nice distraction.

Dear fanfic writer:

Wednesday, December 10th, 2025 06:54 am[personal profile] conuly
conuly: (Default)
I can see you're not a cook. You can't exactly dice thyme. The leaves are pretty tiny. If they're fresh, you just strip them from the stem. I suppose you can then chop them more finely, but dicing? You'd have more luck trying to dice time.

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testing DW image problem

Sunday, December 7th, 2025 02:43 am[personal profile] darkoshi
darkoshi: (Default)
This is a test. Images that I post, including ones in my old posts, no longer display right on Dreamwidth...
JPG:


PNG:


I have submitted a support request.

over the air TV: ATSC 3.0 aka NextGen TV

Sunday, December 7th, 2025 01:16 am[personal profile] darkoshi
darkoshi: (Default)
I don't have any ATSC 3.0 television stations in my area and didn't realize it is already fairly widespread in the U.S. (map).

CNET: Free antenna TV is getting an upgrade and it might be in your town already Jan. 20, 2022
4K, HDR, 120Hz refresh rates and better indoor reception are coming to US airwaves for free thanks to ATSC 3.0, aka NextGen TV. ...

I Reviewed an ATSC 3.0 TV - Built-in DVR, More Channels, HDR10+ Video - YouTube video by Antenna Man, 2025/06/13.
Conclusion: Paying extra for ATSC 3.0 is probably not worth it. unless TV reception is bad in your area; the ATSC 3.0 channels may have better reception than the 1.0 channels.

The Downfall of ATSC 3.0 NextGen TV - What Went Wrong? - YouTube video by Antenna Man, 2025/10/24.

(no subject)

Tuesday, December 9th, 2025 09:53 pm[personal profile] conuly
conuly: (Default)
The Trump administration’s NSS announces a dramatic reworking of the foreign policy the U.S. has embraced since World War II.

And that's not the most alarming thing about it.

(no subject)

Saturday, December 6th, 2025 11:11 am[personal profile] neekabe
neekabe: Bucky from FatWS smiling (Default)
Got my covid shot today!
And picked up a couple of meters of fabric again 😅

But it's like getting a suckers after your shot as a kid.

cleaning up clutter

Saturday, December 6th, 2025 05:27 am[personal profile] darkoshi
darkoshi: (Default)
It took me all day to clean out one small box out of many that I have around the house. This one had a few items I brought back from Qiao's house after breaking up with him. Deciding what to do with each item. Where to put them, and which things not to keep. It takes me forever.

The dog tags were the hardest. I finally found a small cushioned box to keep them in.

The colorful shiny metallic foil chocolate wrappers compacted into various shapes, I put together with others, in a bigger box with clear lid.

..

I came across the receipt of a 14" flat CRT TV and a Memorex DVD player I bought from Sears in 2006. The TV cost $99. The DVD player cost only $34.99! Both prices were much less than I would have guessed. I still have the TV in a bedroom though I rarely use it. My mom has the DVD player; I have other DVD players now.

I also have a large CRT TV which used to be Qiao's; he didn't want it anymore. As well as an extra LED TV which I was going to replace the CRT with. But the CRT TV turns on instantly while the LED TV (a Toshiba FireTV - avoid them is my advice) sometimes takes several minutes. I suppose I will eventually get rid of the CRT. I don't know if I can find someone local who would want it, considering it still works. I might have to pay someone to take it to the dump. Or take it myself if it's not the horrible smelling landfill place that it would need to go to.

..

On the coffee table is a row of audio cassettes, on which I had copied music for Qiao back when he had a vehicle that played cassettes. I still have the original copies of the music; I don't need the cassettes. So I don't know what to do with them, and they sit there and sit there. I could erase them and take them to Goodwill, I guess? I have occasionally seen home-recorded tapes like that at Goodwill which weren't erased. But I don't think I'd do that.... Hmm, then again what could it hurt. They won't have my name. They won't follow me home to arrest me for having copied copyrighted music to audio cassettes, and then having given the cassettes away.

If someone wants the cassettes for recording their own music to, they can record over them. And if they get a kick out of listening to the music that's already on them, that's great too. But cassettes are old tech; few people would probably want them either way.

Well good, that's one decision made, and an easy solution. Give them to Goodwill in a box along with other stuff I've already put aside to take there.

Neologism: Beginner's Lock

Friday, December 5th, 2025 12:00 am[syndicated profile] ash_feed

Posted by The Doctor [412/724/301/703/415/510]

Beginner's lock: When you get a new lock for your collection and pick it open a couple of times without a whole lot of trouble. Then you put the lock down for a day or so and subsequently have absolutely no luck getting it open again for weeks or months.

ref., beginner's luck

conuly: (Default)
Which, good for her, but she's not going to make the big bucks in social work, which is what she's getting her BS in. Well, best of luck to her anyway. (She does have her eyes wide open, because everybody has told her that. Unsurprising.)

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Generosity

Thursday, December 4th, 2025 09:15 pm[personal profile] lhexan
lhexan: as a fox, i ride the book and yip (Default)
From a discussion on The Digital Antiquarian.

For some reason I felt the urge to write an essay here. Well, I can put it up on my Dreamwidth account later.

One of the biggest gulfs between the early days of both console and computer games, and their mature contemporary state, is in what it means for a game to respect its player and its player’s time.

In the early days, a respectful game was above all a generous game, one in which you could lose yourself for days or weeks in what was, at the time, an expensive investment. Think of the hours spent wandering Zork: most of those hours are not fruitful, but you’re still rewarded by its very sense of place.

For some console games, the action-oriented ones, this generosity expressed itself as gameplay whose required skills were a joy to learn, paired with escalating challenges to test those skills. For console RPGs, however, the generosity expressed itself simply by rewarding investment with progress. If this seems too obvious to credit, that’s because you’re on the far side of the gulf.

The good games paced their rewards superbly. In particular, I think of the best of the early Final Fantasy and Dragon Quest games, where merely fighting the monsters you saw while walking from destination to destination would make the boss fights challenging but surmountable. (In contrast, the bad JRPGs would require you to halt and grind repeatedly.) That mechanic, however, became a problem as technology developed. Early on, requiring you to level on numerous random encounters was the only way a console RPG could be long, generous in that regard. Data on cartridges was scarce; Dragon Warrior 4, a grand story with unmatched emotional impact (for the NES) and a tragic villain, took up 256kB. Soon enough, however, random encounters became a contrivance, and the RPGs went from long to bloated.

Personally, I still place Final Fantasy 7 on the side of being respectful, but there are factors no longer at play. One of the factors is its sheer spectacle, the game being unmatched in the quality of its animations. These no longer impress, but back then summoning one of the Bahamuts was a joy every time. (Its sequel, among its many other problems, placed too much priority on spectacle. The lengths of its summon animations were widely mocked.) However, with CDs on the scene, the technological need for random encounters as a way to lengthen a game was no longer there. It had become a trope, sometimes executed well, sometimes poorly, and its artifice would only become more apparent as time went on.

To return to the earlier point. The gulf exists because it became possible for something resembling this aforementioned generosity to be manufactured. For the larger companies, making a game long was a solved problem, a matter of effective management of large teams. Likewise, such games were full of rewards, and generous in that limited sense. But they were no longer respectful; some, like the Assassin’s Creed, were downright condescending in how little their rewards meant. Early on, you could love a game because it gave you forty hours’ worth of story and gameplay, in a time when few other games did. Now, no-one could love a game simply for being long.

What does it mean now for a game to be respectful of its players? I don’t know; I don’t have a general answer. Dark Souls is respectful, but in a profoundly different way than Super Mario Odyssey is respectful. I do, however, think that the emphasis on time remains: a respectful game is a game that respects its player’s time.

One more thing before I wrap up this silliness. Final Fantasy VII’s oft-derided huge-handed character models exist because, in the at-the-time undeveloped field of model animation, Square took inspiration from marionetting: outside of its combats, its characters are animated like puppets. This is not only an animation technique; it also becomes an explicit theme of the game. Even decades on, I don’t want to spoil you, so I’ll just say this: when you find Aeris again, take the scene very slowly. There’s something very interesting that happens before the part everyone remembers.

Matt: Interesting mini-essay Lhexa. Of course, seems to me like its worth noting that all this is also a function of not necessarily an idealized player free of context that stays the same across eras, but what we (or rather the game’s producers and planners) expect that player’s other life commitments and their alternative options to be. For a early teen child in the early era, without Youtube/TikTok, without internet, it’s perhaps different from what many of a typical player would be today. And so this changes over time, with the technological landscape, how more entertainment becomes cheaply available, and so the “opportunity cost” of playing more hours in a game (i.e. what else could you be doing instead?), and also the expected age range and lifestyle of players.

It’s quite a challenge in particular to reconcile the ideals of “openness” and “freedom”, which is that you can go anywhere you can see, do anything and make choices about everything – and which older players tend to expect more of – with managing to ensure that this time always includes something fun or exciting – naturally much easier to ensure in more linear and “directed” games. This leads to the sort of contemporary complaints about games that superficially seem large and open, but on closer inspection are found to have most of that large world simply be merely shepherding players between map markers that ask them to fetch and deliver miscellaneous items and spent a lot of time walking or using fast travel via menus. (Hideo Kojima’s ‘Death Stranding’ could be viewed as a veteran designer’s slightly sly “Well, OK guys, if this is what you really want” parody of this, as well as in earnest a modern high budget game).


Thanks for the response, Matt. Looking back on it, my essay’s historical argument is too simplistic to endorse, but it least I was able to develop my ideas of “respect” and “generosity” in gaming a bit further.

I agree that there’s no idealized player that we can appeal to, and that’s a large part of why the value of early games like Final Fantasy VII requires extra effort to perceive nowadays. One thing that intrigues me is the possibility of further paradigm shifts in gaming; in fact, we seem to be in the midst of one now, with the concept of “games as services” emerging from the domain of MMOs to cover many other genres. I’m accustomed to thinking of games as discrete experiences, like books or movies, but there’s now quite a few people for whom (individual!) games are more like lifestyles.

Openness was revolutionary when it when first appeared in the console space, but in retrospect it was more of a technological innovation than a design innovation. Kinda like how Quake’s primary innovation was technology more than design, revolutionary though it felt at the time. As for freedom, the player can only do what the designers allow them to do, so freedom is a matter of designers not turning around and constraining what abilities previously they granted (for instance by having varied movement options but then placing lots of invisible walls), rather than granting them a large number of abilities in the first place. I’m not going anywhere with this, just rambling.

Day 1780: "A bloated, useless entity."

Thursday, December 4th, 2025 03:41 pm[syndicated profile] wtfjht_feed

Posted by Matt Kiser

Day 1780

Today in one sentence: The Supreme Court allowed Texas to use its new congressional map for the 2026 elections, blocking a lower court ruling that found the plan was likely a racial gerrymander; federal agents arrested the man accused of planting pipe bombs outside the RNC and DNC offices the night before Jan. 6 Capitol attack; the Government Accountability Office opened an investigation into Bill Pulte after Senate Democrats accused the Federal Housing Finance Agency director of abusing his position to target Trump’s perceived political enemies with criminal referrals; the Trump administration renamed the U.S. Institute of Peace to the “Donald J. Trump Institute of Peace”; 98% of more than 2,100 Foreign Service employees reported lower morale this year; 46% of Americans say the cost of living in the U.S. is worst than than they can ever remember; and U.S. economic confidence fell to negative 30 in November – its lowest level since July 2024.


1/ The Supreme Court allowed Texas to use its new congressional map for the 2026 elections, blocking a lower court ruling that found the plan was likely a racial gerrymander. The order granted an emergency request from Gov. Greg Abbott after a three-judge panel said Republican lawmakers, acting at Trump’s urging, diluted the voting power of Black and Latino residents. The justices said Texas was likely to win on appeal and paused the injunction while they review the case. The map was designed to add up to five Republican House seats. (NBC News / Associated Press / Bloomberg / Wall Street Journal / Politico)

2/ Federal agents arrested the man accused of planting pipe bombs outside the RNC and DNC offices the night before Jan. 6 Capitol attack. An FBI affidavit said investigators tied Brian Cole Jr. to the devices through purchase records, cellphone data and a license plate reader, though officials didn’t explain why earlier reviews of the same evidence failed to identify him. (Associated Press / NBC News / New York Times / CNN / Washington Post)

3/ The Government Accountability Office opened an investigation into Bill Pulte after Senate Democrats accused the Federal Housing Finance Agency director of abusing his position to target Trump’s perceived political enemies with criminal referrals. The probe will examine whether Pulte and FHFA staff misused federal authority and resources in sending mortgage fraud referrals on New York Attorney General Letitia James, Sen. Adam Schiff, Rep. Eric Swalwell, and Federal Reserve Governor Lisa Cook to the Justice Department. A federal judge has already dismissed charges tied to Pulte’s referral of James. (Reuters / NBC News / Axios / CNBC)

4/ The Trump administration renamed the U.S. Institute of Peace to the “Donald J. Trump Institute of Peace,” bolting his name onto its Washington headquarters. The State Department said the rebranding honors “the greatest dealmaker in our nation’s history” and will stand as a reminder of “what strong leadership can accomplish for global stability.” The White House, meanwhile, called the Institute of Peace a once “bloated, useless entity,” but the Donald J. Trump Institute of Peace “is both beautifully and aptly named after a President who ended eight wars in less than a year.” The move follows Trump’s February order to shut down the congressionally created institute and a March takeover by the Department of Government Efficiency, which removed the leadership and fire most staff. (NPR / CNN / Axios / New York Times / Bloomberg / Washington Post / NBC News)

5/ 98% of more than 2,100 Foreign Service employees reported lower morale this year. The American Foreign Service Association said workplace changes since January have made it harder to advance U.S. diplomatic priorities and warned that thousands of departures and ongoing reductions in force have left the State Department struggling to sustain core functions. (New York Times / Axios / Federal News Network)

poll/ 46% of Americans say the cost of living in the U.S. is worst than than they can ever remember. 46% also say this is now Trump’s economy and he’s responsible for the high costs. (Politico)

poll/ U.S. economic confidence fell to negative 30 in November – its lowest level since July 2024. 21% of Americans described current economic conditions as good in November, while 40% described conditions as poor. 27% said the economy is getting better, while 68% said the economy is getting worse. (Gallup)

⏭️ Notably Next: The 2026 midterms are in 334 days.



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Life with two kids: Christmas monitoring

Thursday, December 4th, 2025 07:31 am[personal profile] andrewducker
andrewducker: (Default)
Opening up my YouTube Recap so I can find out what nonsense Gideon has been watching this year.

(Sophia is on her own account, but for technical reasons Gideon can't be yet.)

Switched shifts

Friday, December 5th, 2025 05:17 am[personal profile] conuly
conuly: (Default)
so now I'm spending some part of my evening with another coworker instead of by myself, which means I can't just summarily turn off the TV. Other people are weird when they want the TV on even if they aren't watching it, but since they think I'm weird for preferring blissful silence I guess sometimes I have to compromise.

Which means that the other day my entertainment choices were either a long and frankly tedious piece on the JFK conspiracy theories, or HP1. Welp, JFK won't get any deader, and practically speaking, JKR won't get any richer. The choice wasn't really very agonizing, is what I'm saying. I feel like maybe it ought to have been, but no. (That place does not have enough channels. If I'm going to be stuck watching TV for even part of the night I really need to figure out how to get my phone on the screen.)

All this led me to realize something that I somehow don't think I ever thought about before, which is that the plot of book 2 doesn't make any fucking sense, like, right from the start. How exactly did Lucius set it up so that he'd happen to bump into the Weasley family? What if they hadn't gone shopping that day? There clearly was a lot of planning that went into this, so what was his backup? Really, none of those plots hold together if you look at them too hard. And that's not too unusual for fiction, but I'm not particularly inclined to be charitable about it.

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