Types of Insurance
Plans
Plans
A health plan with a limited network of local doctors and hospitals, usually offering lower monthly premiums. It often requires choosing a primary care physician and getting referrals for specialists, promoting integrated care.
What is a Health Maintenance Organization or HMO?
HMO
What is a Health Maintenance Organization?
A fixed fee a patient pays for a medical service at the time of service, in addition to the service cost. It's a cost-sharing method where the patient pays part of the cost, and the insurance covers the rest.
What is Co-pay or Co-Insurance?
A formal request from a primary care physician to a specialist for specialized medical care. It's like a "ticket" allowing the patient to access specialized care within their insurance plan. These are often required by certain health insurance plans, like HMOs, to ensure coordinated care and may affect coverage and costs.
What is a referral?
The fee you pay to have insurance. If you get health insurance through your employer, they may pay all or part of your of this.
What is a premium?
A health plan with a larger network, offering more choices of doctors and hospitals. It typically has higher out-of-pocket costs, and does not require a primary care physician or insurance referrals.
What is a Preferred Provider Organization or PPO?
PPO
What is a Preferred Provider Organization?
A financial protection plan against high healthcare costs, where you pay a monthly fee to an insurance company. In return, they cover part of your medical expenses, such as doctor visits, hospital stays, and surgeries.
What is insurance coverage?
This is a process where your health plan must approve coverage for the service that your doctor or you requests. Your health insurer can require this for certain services before you receive them, except in an emergency.
What is pre-authorization?
A written contract between a policyholder and an insurance company, outlining their duties and responsibilities. It may include documents like applications, endorsements, or certificates that describe, limit, or exclude coverage benefits.
What is an insurance policy?
A US government program that provides health insurance to individuals and families with low incomes or limited resources. It's a federal and state partnership, meaning it's jointly funded and administered by both the federal government and individual states.
What is Medicaid?
EPO
What is an Exclusive Provider Organization?
In health insurance, this is the amount of money you pay for covered healthcare services before your insurance starts to pay. It's essentially your out-of-pocket expense for medical care until your insurance kicks in.
What is a deductible?
The most you pay during a year before your health insurance company begins to pay 100% of the allowed amount.
What is out of pocket limit?
The doctor you choose to provide basic health care. In an HMO, this provider must refer you to a specialist if you need to see one.
What is a primary care physician?
The federal health insurance program in the United States for people 65 and older, and certain younger individuals with disabilities or end-stage renal disease (ESRD). It is a program managed by the Social Security Administration (SSA).
What is Medicare?
MassHealth
What is the Medicaid Program in Massachusetts called?
A healthcare model that aims to improve patient care coordination and quality while reducing costs. It is a network of providers working together, not an insurance company. These type organizations partner with insurance companies, Medicare and state Medicaid programs to offer coordinated care, focusing on preventive care and managing chronic conditions to reduce hospitalizations and expenses. Patients choosing an ACO may receive insurance benefits like lower premiums due to efficient care delivery.
What is an ACO?
The facilities, providers, labs, hospitals, and pharmacies that your health plan has contracts with to provide health care.
What is in network or network?
A health professional or organization that provides health care services, such as a doctor, physical therapist, hospital, lab, or clinic.
What is a provider?
A type of health plan that offers a local network of doctors and hospitals for you to choose from but networks are generally larger than HMO networks. This plan is usually more pocket-friendly than a PPO plan.
What is an Exclusive Provider Organization or EPO?
ACO
What is an Accountable Care Organization?
A federal law that protects patient health information privacy, ensuring responsible use and disclosure. It helps people maintain health insurance during job changes or losses and aims to reduce healthcare fraud and abuse. It applies to health plans, healthcare clearinghouses, and providers who transmit health information electronically.
What is HIPAA?
Sometimes called "Medi-gap", these are insurance policies that you can purchase to pay for things that Medicare does not cover. The insurance supplements (hint), or closes the gap, between what Medicare pays for and what it does not.
What is Medicare Supplemental Insurance?
This is the department where you will refer a patient who has non-contracted insurance and will be self-pay. Also, these types of plans cannot be self-pay.
What is the PFE or Patient Financial Experience Department? What is Medicare, MassHealth (ACO and MCO plans) or Medicaid out-of-state patients?