Major medical insurance plans

Health Maintenance Organization

an insurance plan with low monthly premiums. low copayments and deductibles, and low total cost for the patient.

Patients are restricted (except in emergencies) to a limited panel of providers who are in the network. Payment is denied for any service that does not meet established, evidence-based guidelines. Requires referral from primary care provider to see a specialist.

Point of Service (POS)

Patients are allowed to see providers outside of the network, but have higher out-of-pocket costs, including higher copays and deductibles, for out-of-network services. Requires referral from primary care provider to see a specialist.

Preferred Provider Organization (PPO)

Patients are allowed to see physicians who are within or outside of the network. And, Does not require referral from primary care provider to see a specialist. All services have higher copays and deductibles (than HMO plans).

Exclusive Provider Organization

Patients are limited (except in emergencies) to a network of doctors, specialists, and hospitals. Does not require referral from primary care provider to see a specialist.

Medicaid is a joint federal and state program to cover low-income patients. Patients who have full-time employment and employer-sponsored health insurance.Medicare is a federal health insurance program for patents who are age >65, disabled, or have end-stage renal disease or ALS.Part A covering inpatient hospital visits,

Part B covering a select number of outpatient services and medical devices,

Part C as an optional capitated plan with additional benefits (vision, dental), and

Part D as an optional prescription drug plan.

Healthcare payment models

Capitation

Physicians receive a set amount (fixed, predetermined fee) per patient assigned to them per period of time, regardless of how much the patient uses the healthcare system.

It is the payment structure underlying Health Maintenance Organization (HMO) provider networks.