PROVIDERS OF HEALTHCARE PLANS

• Service Providers
• Commercial Insurers
• Self Funded
• The Government

• Profit or non-profit
• Who receives the benefits
• Choice of physicians and hospitals

Blue Cross Blue Shield - contract is between the provider of health care (hospital/doctors) and the Blues.

Pay is on Service basis - payments directly to the doctors & hospitals, the providers of the health care

Individuals are called MEMBERS and never directly receive benefit payments.

Health Maintenance Organizations (HMO)- organize and deliver the actual healthcare on a prepaid basis in a specific geographic areas known as the service area

Reduce medical expenses by emphasizing ROUTINE health care by stressing prevention

Can own medical facilities staffed with salaried physicians as well as contact with a network of physicians practicing independently. 

Required to choose a PRIMARY CARE PHYSICIAN

Must have a referral from primary care physician to see a specialist physician

Preferred Provider Organizations (PPO)- Managed healthcare systems where the insurance company negotiates with physicians and hospitals to provide medical services on a prearranged "fee for service basis".  

• Use of preferred porovider receive 100% payment
• Other physicians and facilities the insurer will pay a reduced benefit

Benefits of PPO

• More choices of physicians than HMO
• Physicians are not employees of PPO
• PPO pay on SERVICE basis- agreed to in advance
• NO primary care (gatekeeper) required

Stock Insurers and Mutual Insurers: Organized for profit.  Contract is between the insured and the insurer.

• Operate on reimbursement basis
• Payable directly to the insured
• May assign right of payment of benefits to the healthcare provider

Multiple Employer Trust (MET)- many smaller employers combine their resources to provide group health

• A trust is established
• Can be self funded or funded through insurance contracts

Multiple Employer Welfare Arrangements (MEWAs) - one or more large employers combine resources to provide group health on a group basis

Medicare

• 65 and over, or who meet other special criteria
• Federal government administered

Medicaid

• Financially impoverished and not able to pay for his/her medical needs
• Combination of Federal & State Admin

Tricare 

• Members of the armed services, their families, (dependents) and survivors
• Funded by the US Department of Defense