Show:
HMO Plans
PPO Plans
High Deductible Health Plans
Indemnity Plans
Laws and Mandates
100
"HMO"
What is ... Health Maintenance Organization
100
"PPO"
What is ... Preferred Provider Organization
100
"HDHP" and "CDHP"
What are ... High Deductible Health Plan and Consumer-Driven Health Plan
100
Allows you to direct your own health care and visit almost any doctor or hospital you like. The insurance company then pays a set portion of your total charges. Also referred to as "fee-for-service" plans
What is ... Indemnity Plan
100
Gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan.
What is... The Consolidated Omnibus Budget Reconciliation Act (COBRA)
200
Network of providers; Primary Care Physician (PCP) who coordinates all care; May not reimburse for out-of-network coverage; Typically require referrals for specialists Copays
What are ... HMO Plan Characteristics
200
Typically two levels of coverage (in-network/out-of-network); Complete choice over selection of providers; Coinsurance after the deductible; May pay different percentages based upon in and out-of-network providers
What are ... PPO Plan Characteristics
200
Within an HMO or a PPO, depending on deductible limit; Insured pays nearly all of the medical bills up to the deductible; Lower premiums, but higher deductibles than traditional plans; Insured has greater financial control
What are ... High Deductible Health Plan Characteristics
200
Deductibles; Coinsurance requirements; No network; Same benefits regardless of provider used; No PCP; No referrals
What are... Indemnity Plan Characteristics
200
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease or other health problems
What is ... Preventive Services
300
Most disciplines are located within one facility; doctors may be employees of the HMO; Great potential for cost Savings.
What is ... HMO Staff Model
300
Occurs when out-of-network (OON) physicians, hospitals, and other health care providers bill patients for the difference between a billed charge and a health plan's allowed amount
What is ... Balance billing
300
High Deductible Health Plan plus a Tax-advantage spending account (HSA/HRA)
What is ... Consumer-Driven Health Plan (CDHP)
300

Benefits are the same regardless of the provider used

What is ... Indemnity plan coinsurance

300
Enacted into law March 2010; 3 primary goals: 1. Make affordable health insurance available to more people. 2. Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. 3. Support innovative medical care delivery methods designed to lower the costs of health care generally.
What is ... The Patient Protection and Affordable Care Act (PPACA / often referred to as ACA)
400
Participating physicians practice in their own office; Usually have contractor arrangements with hospitals to provide inpatient care
What is ... HMO Independent Practice Associations (IPA) Model
400
Narrower network than a traditional PPO with higher member costs for out-of-network providers
What is ... Point of Service Plan (also an EPO - Exclusive Provider Organization)
400
Non-grandfathered health plans cannot allow any individual, including those with family coverage, to spend more than the individual out-of-pocket (OOP) maximum established under Patient Protection and Affordable Care Act (PPACA).
What is ... Embedded Individual Out-of-Pocket Maximum
400
You seek high levels of flexibility and choice for doctors and hospitals, are fine with the balance of higher rates in exchange for more service control, can accept the burden of potentially increased administrative activity for referral and claims paperwork
What is ... Why an indemnity plan may be a good option for you.
400
Federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits.
What is ... Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)
500
Largest HMO provider in the Portland Oregon area
Who is ... Kaiser Permanente (NW)
500
Provider groups of physicians and hospitals, providing coordinated and comprehensive care across the patient health continuum with a "triple aim" to (1) improve member health and clinical outcomes, (2) reduce member cost and (3) improve member experience and satisfaction
What is ... Accountable Care Organizations (ACO)
500
Requires the entire family deductible to be met before the medical plan will share the cost of a claim (coinsurance) for any family member.
What is ... A True Family Deductible
500
No network discounts
What is ... Main reason indemnity insurance is most expensive
500
The Affordable Care Act requires non-grandfathered health plans in the individual and small group markets to cover what type of benefits which include items and services in the following ten benefit categories: (1) ambulatory patient services; (2) emergency services; (3) hospitalization; (4) maternity and newborn care; (5) mental health and substance use disorder services including behavioral health treatment; (6) prescription drugs; (7) rehabilitative and habilitative services and devices; (8) laboratory services; (9) preventive and wellness services and chronic disease management; and (10) pediatric services, including oral and vision care.
What is ... Essential Health Benefits