PPOs
Contracted provider plans
PPOs are preferred provider organizations—health insurance plans that contract with networks of doctors and hospitals to provide care at reduced rates.
Members pay less when using in-network providers but can see out-of-network providers at higher cost without a referral: Most employers offer a choice between PPOs and HMOs.
The flexibility comes with higher premiums than more restrictive plans.
Added cost for better
- deductibleOut-of-pocket threshold amount
- copaymentPatient's fixed healthcare charge
- coinsurancePercentage you owe
- out-of-pocket maximumAnnual spending limit on coverage
annual limit · reimbursement · cost-sharing · expenses · claims processing
Contracted with your insurer
- out-of-networkOutside approved provider list
- preferred providersDesignated first-choice vendors
- specialistsFocused field authorities
- primary care physicianMain healthcare provider
Gains or helpful effects
- exclusionsThings deliberately left out
- inclusionsThings placed within
- preauthorizationPermission obtained beforehand
- prior approvalPermission sought beforehand
medical necessity · preventive care · emergency care · prescription coverage · mental health · surgery · treatment · hospitalization
Cost-controlled health delivery
- HMOsPrepaid healthcare networks
- fee-for-servicePayment per procedure rendered
- open accessFree public scholarly content
Owner of insurance contract
- enrolleeOne officially signed up
- memberOne who belongs
- open enrollmentDesignated benefits signup window
- employer-sponsoredFunded by one's workplace
premium
Added cost for better
- deductibleOut-of-pocket threshold amount
- copaymentPatient's fixed healthcare charge
- coinsurancePercentage you owe
out-of-pocket maximum · annual limit · reimbursement · cost-sharing · expenses · claims processing
in-network
Contracted with your insurer
- out-of-networkOutside approved provider list
- preferred providersDesignated first-choice vendors
- specialistsFocused field authorities
primary care physician · hospitals · clinics · flexibility · direct access
benefits
Gains or helpful effects
- exclusionsThings deliberately left out
- inclusionsThings placed within
- preauthorizationPermission obtained beforehand
prior approval · medical necessity · preventive care · emergency care · prescription coverage · mental health · surgery · treatment · hospitalization
managed care
Cost-controlled health delivery
- HMOsPrepaid healthcare networks
- fee-for-servicePayment per procedure rendered
- open accessFree public scholarly content
policyholder
Owner of insurance contract
- enrolleeOne officially signed up
- memberOne who belongs
- open enrollmentDesignated benefits signup window
- healthcaredoctors, nurses, hospitals, hospital, clinic
- health organizationshospital, clinic, WHO, CDC, NIH
- US Medical Historypolio vaccine, Jonas Salk, Salk vaccine, Clara Barton, Walter Reed