Commercial/Private

This is a traditional health plan (not an HMO or PPO) that permits an insured individual to select his or her own physician, specialist, hospital or other provider.

Under an indemnity plan, the individual pays for services directly to the provider and then is reimbursed by the carrier. The fees for services are defined by the providers and vary from physician to physician. Indemnity health plans are also known as "fee-for-service" plans.

Managed care is an approach to healthcare intended to streamline services and provide healthcare that is quality and cost effective. Through supervision, monitoring, and advising, managed care programs seek to ensure a certain standard of care, measure performance, and control costs. Additionally, some managed care plans seek to assist members in staying healthy through prevention.

• Utilization review components:
• • Oversee and keep track of the types and amounts of services obtained by members.
• Provider reimbursement methods:
• • Used to discourage members from receiving healthcare services that are deemed unnecessary, according to the guidelines of the plan.

Any insurance policy or health services contract by which groups of employees (and often their dependents) are covered under a single policy or contract, issued by their employer or other group entity.

A health plan whose costs are borne solely by the individual, usually costing more than group or pooled insurance.

A health plan under which an insurer or MCO bears the financial responsibility of guaranteeing claim payments and paying for all incurred covered benefits and administration costs

A health plan under which an employer or other group sponsor, rather than an MCO or health plan, is financially responsible for paying plan expenses, including claims made by group plan members. Also known as a self-insured plan.

A contract under which a third party administrator or an insurer agrees to provide administrative services to an employer in exchange for a fixed fee per employee.

The process a health plan and/or employer uses to determine which benefits or the level of benefits that will be offered to its members, the degree to which members will be expected to share the costs of such benefits, and how a member can access medical care through the health plan.

Blue Cross/Blue Shield plans are a federation of individual, usually not-for-profit companies which typically operate only in the state in which they are located. These plans contract directly with physician, hospitals and various other health entities to provide services to their insured companies and individuals. Blue Cross plans primarily provide hospital services, outpatient care, some institutional services and home care. Blue Shield provides physician services (and in some cases dental, outpatient and vision care). Most BC/BS plans offer health maintenance organizations, preferred provider organizations and point-of-service plans in addition to group and individual fee-for-service plans.

Commercial carriers are private, for-profit companies that provide group and/or individual plans. Premiums and coverage are determined by each company (e.g., Aetna, United Healthcare, Humana). Commercial carriers have historically offered traditional indemnity health plans that reimburse fee-for-service with the insurance covering 80 percent of the health plan allowance and the patient being held responsible for the remaining 20 percent copayment. Most commercial health plans have predefined patient deductibles and copayment provisions. Generally, physicians do not have special contract agreements with commercial carriers.

A type of Managed Care Organization (MCO) that provides health plan coverage through a network of hospitals, doctors, and other providers. Under this model, providers contract with an HMO to receive more patients and in return usually agree to provide services at a lower rate. This arrangement allows the HMO to charge a lower monthly premium. Patient is required to select a Primary Care physician and must obtain a referral in many cases to seek specialty care services. The patient typically does not have a deductible and copays are usually predetermined flat fees ($5, $10, etc.). Generally no benefits for services provided out of network without a referral.

A type of group health plan usually organized by an insurance company in which medical professionals in the system agree to accept a standard fee schedule and patient care controls, and the policyholder can go to any medical provider in the network and pay the co-payment amount for each regular service. If the policyholder chooses to get an out-of-network provider, s/he often pays that doctor's fee directly and files for reimbursement from the health plan. Because this is a greater cost, the PPO system encourages its policyholders to see the doctors and health providers who are part of the network. No referrals are required for specialty care.

This type of policy has characteristics of both HMO and PPO plans. Like an HMO, the individual designates an in-network physician to be their primary care provider. However, like a PPO, a POS plan lets the individual go out-of-network. When the individual goes out- of-network, they will have to pay a portion of the cost, unless the primary care physician refers them to an out-of-network doctor.

A national program that lets members of one Blue Cross Blue Shield company obtain health care services while traveling or living in another Blue company's service area. BlueCard Worldwide® provides members with access to a network of traditional inpatient, outpatient and professional healthcare providers around the world. The program includes a range of medical assistance and claim support services for members traveling or living in countries outside their Home Plan service area.

Formerly called Medical Savings Accounts (MSAs), a method of financing health care by giving tax advantages to individuals who establish and maintain personal accounts for health care purposes; similar to an Individual Retirement Account for retirement purposes. The health savings account legislation was signed into law in 2003, making the HSA the next generation of MSA plans.

Q: What are the major differences between a HMO and PPO plan?

A: A person who is enrolled in an HMO plan must select a primary care physician who is responsible for coordinating their care. In many cases, the person must obtain a “referral” from the primary care physician prior to seeing a specialist. In addition, the patient must seek care within the HMO network unless the primary care physician obtains an authorization for care outside of the HMO network. In a PPO plan, the patient does not have to select a primary care physician and does not need a referral to seek care from a specialist. However, the patient will typically have different deductibles and coinsurance based on whether the patient seeks care in or out of network.

Q: If the plan has a medical policy stating that a specific device meets their “medical necessity” requirements for coverage does this mean that every patient who has that specific health plan has coverage for this device?

A: No, even though the health plan has a universal medical policy stating what devices, services, procedures are considered “medically necessary” each employer group or individual will have specific benefit plans that dictate of whether a device, service, or procedure is covered.

Q: How can an audiologist, patient, or physician find out whether a patient has coverage for a specific device, procedure, or service?

A: There are several ways to find out whether the patient has specific coverage and the amount of coverage for a device, procedure, or service. First, the patient can contact their plan’s member services department. The phone number is usually listed on the back of their health plan identification card. Second, the physician or audiologist can verify benefits by calling the health plan and can also submit a pre-determination of benefits prior to providing services.