HMOs
Network-based health plans
HMOs are health maintenance organizations—a type of health insurance plan that provides medical care through a network of doctors and hospitals.
Members typically choose a primary care physician who coordinates their care and provides referrals to specialists.
HMOs generally offer lower premiums but less flexibility than other insurance types: My HMO won't cover out-of-network providers.
One controlling entry
- preauthorizationPermission obtained beforehand
- primary care physicianMain healthcare provider
- capitationPer-capita fixed payment
- clinical guidelinesOfficial medical treatment recommendations
disease management · case management · quality assurance · evidence-based medicine · wellness programs · health promotion · formulary · prior approval
Payments for insurance coverage
- deductiblesPre-coverage personal payments
- copaymentsPatient's portion of charges
- co-insuranceShared claim payment arrangement
- out-of-pocket maximumAnnual spending limit on coverage
capitation · cost-sharing · generic drugs · tiered pricing · administrative costs · affordability · subsidies
Those who furnish
- physiciansMedical doctors collectively
- specialistsFocused field authorities
- hospitalsInstitutions treating the sick
- clinicsOutpatient treatment facilities
primary care · referrals · panel · pharmacies · laboratories · telemedicine · access
Act of registering officially
- subscribersThose enrolled for content
- beneficiariesThose who receive advantages
- membersPeople in an organization
- open enrollmentDesignated benefits signup window
group plan · individual plan · family plan · employee benefits · employer-sponsored · renewal · disenrollment · portability
Gains or helpful effects
- exclusionsThings deliberately left out
- eligibilityState of meeting criteria
- in-networkContracted with your insurer
- out-of-networkOutside approved provider list
preventive care · prescription coverage · maternity · emergency services · hospitalization · outpatient services · dental · vision
Official permission to operate
- accreditationOfficial quality approval
- patient rightsLegal protections for care recipients
- appeal processProcedure for contesting decisions
- consumer protectionLaws defending purchasers' interests
gatekeeper
One controlling entry
- preauthorizationPermission obtained beforehand
- primary care physicianMain healthcare provider
- capitationPer-capita fixed payment
clinical guidelines · disease management · case management · quality assurance · evidence-based medicine · wellness programs · health promotion · formulary · prior approval
premiums
Payments for insurance coverage
- deductiblesPre-coverage personal payments
- copaymentsPatient's portion of charges
- co-insuranceShared claim payment arrangement
out-of-pocket maximum · capitation · cost-sharing · generic drugs · tiered pricing · administrative costs · affordability · subsidies
providers
Those who furnish
- physiciansMedical doctors collectively
- specialistsFocused field authorities
- hospitalsInstitutions treating the sick
clinics · primary care · referrals · panel · pharmacies · laboratories · telemedicine · access
enrollment
Act of registering officially
- subscribersThose enrolled for content
- beneficiariesThose who receive advantages
- membersPeople in an organization
open enrollment · group plan · individual plan · family plan · employee benefits · employer-sponsored · renewal · disenrollment · portability · COBRA
benefits
Gains or helpful effects
- exclusionsThings deliberately left out
- eligibilityState of meeting criteria
- in-networkContracted with your insurer
out-of-network · preventive care · prescription coverage · maternity · emergency services · hospitalization · outpatient services · dental · vision · limitations
state licensing
Official permission to operate
- accreditationOfficial quality approval
- patient rightsLegal protections for care recipients
- appeal processProcedure for contesting decisions
- insuranceinsurance, coverage, auto insurance, life insurance, home insurance
- healthcaredoctors, nurses, hospitals, hospital, clinic
- public healthdisease prevention, immunization, disease control, health education, epidemiology
- health organizationshospital, clinic, WHO, CDC, NIH
- US Medical Historypolio vaccine, Jonas Salk, Salk vaccine, Clara Barton, Walter Reed
HMOsfee-for-service
Payment per procedure rendered
PPOs · single-payer · self-pay · health savings accounts · uninsured