May 2011 Only over 200 million Americans have medical health insurance programs from private or commercial marketplace medical health insurance. Within the last 3 years, the legal and financial structure of such insurance has diverse. Nobody model has dictated the market, even though there are strong tendencies, from the original allowance or fee for service strategy of 25 years ago, to HMOs from the 1990’s, to Preferred Provider Organizations in the previous ten years. The specific terms and structures might be source of confusion, both to policymakers and also to employers and enrollees. The summary definitions below were published and promulgated by the U.S.
Department of Labor. NCSL has added notations in selected cases. The Federal Health Reform Law: The Affordable Care Act of 2010 has many provisions which affect the structure and extent of medical health insurance programs. The Act states that the Secretary shall specify the important health advantages for certain health plans. The law also instructs the Secretary to ensure which the scope of the essential health services is equal to the range of benefits provided under a normal employer program. The Act requires that the Secretary of Labor to conduct a questionnaire of employer sponsored coverage to ascertain the advantages typically covered by companies, and also to report the outcomes of the questionnaire to that the Secretary of Health and Human Services.1 Types of Commercial Health Insurance Indemnity plan A type of medical plan that reimburses the patient and/or provideras expenses are incurred.
Conventional indemnity plan An indemnity which allows the player the option of any supplier without effect on reimbursement. These plans reimburse the patient and/or provider as expenses are incurred. Preferred provider organization program An indemnity program where coverage is provided to participants via a network of selected healthcare providers. The enrollees might go outside that the network, but would incur larger costs in that the shape of higher deductibles, higher coinsurance rates, or nondiscounted charges from that the suppliers. Exclusive provider organization program A more restrictive kind of preferred supplier organization program under which employees must use suppliers from the designated network of doctors and hospitals to get coverage, there’s no coverage for care received from a non network supplier except in an emergency situation. Health maintenance organization A healthcare system which assumes both that the financial risks associated with providing full medical services and the liability for healthcare delivery in a certain geographic area to Health maintenance organization members, usually from return for a fixed, prepaid fee. Financial risk can be shared with the suppliers participating in the HMO. Group Model Health maintenance organization a Health maintenance organization which contracts with a single multi specialty health group to offer care to the HMOs membership.