Financial risk may be shared with the providers participating in the HMO. Health maintenance organization (HMO) - A health care system that assumes both the financial risks associated with providing comprehensive medical services (insurance and service risk) and the responsibility for health care delivery in a particular geographic area to HMO members, usually in return for a fixed, prepaid fee. The enrollees may go outside the network, but would incur larger costs in the form of higher deductibles, higher coinsurance rates, or nondiscounted charges from the providers.Įxclusive provider organization (EPO) plan - A more restrictive type of preferred provider organization plan under which employees must use providers from the specified network of physicians and hospitals to receive coverage there is no coverage for care received from a non-network provider except in an emergency situation. Preferred provider organization (PPO) plan - An indemnity plan where coverage is provided to participants through a network of selected health care providers (such as hospitals and physicians). These plans reimburse the patient and/or provider as expenses are incurred. Indemnity plan - A type of medical plan that reimburses the patient and/or provideras expenses are incurred.Ĭonventional indemnity plan - An indemnity that allows the participant the choice of any provider without effect on reimbursement. The Act further instructs the Secretary to “ensure that the scope of the essential health benefits … is equal to the scope of benefits provided under a typical employer plan.” The Act requires the Secretary of Labor to “conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers,” and to report the results of the survey to the Secretary of Health and Human Services. The Act states that “the Secretary shall define the essential health benefits” for certain health plans. The Federal Health Reform Law: The Affordable Care Act of 2010 (ACA) has numerous provisions that affect the structure and extent of health insurance coverage. NCSL has added notations in selected cases, with source footnotes. The summary definitions below were compiled and promulgated by the United States Department of Labor. The specific terms and structures can be confusing, both to policymakers and to employers and enrollees. No one "model" has dictated the market, although there are strong trends - from the original "indemnity" or fee-for-service approach of 25 years ago, to HMOs (Health Maintenance Organizations) in the 1990's, to "Preferred Provider Organizations (PPOs) in the past ten years. Over the past 30 years, the financial and legal structure of such insurance has varied. Just over 200 million Americans have health insurance coverage from commercial or private market health insurance. Health Insurance Plan Types and Definitions Law, Criminal Justice and Public Safety.Communications, Financial Services and Interstate Commerce.
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