Health Insurance

Premium

The monthly payment made for health insurance, similar to a cable subscription.

Copay

The amount you pay after insurance for a medical visit.

Coinsurance

A percentage of the total cost of a medical visit you are responsible for paying.

Deductible

The amount you must pay out of pocket before your insurance starts to contribute.

Out of Pocket Maximum

The maximum amount you will pay in a year, after which insurance pays 100% of costs.

Formulary

A list of drugs that your health insurance plan covers.

Provider Network

A list of doctors and hospitals that are contracted with your insurance plan.

HMO

Health Maintenance Organization; a type of health insurance plan with no out-of-network coverage.

PPO

Preferred Provider Organization; a type of health insurance plan that offers more flexibility in choosing healthcare providers.

MCO

Managed Care Organization; a healthcare system that controls costs while maintaining quality and access.

Managed Care

Healthcare approaches that emerged in the 70s to address rising healthcare costs and coordinate delivery.

United Healthcare

A provider of HMO, PPO, and Medicare Advantage plans.

Blue Cross Blue Shield

State-based health insurance plans that cover 1 in 3 Americans.

Kaiser Permanente

An insurance company that also provides healthcare delivery services.

Humana

A provider of Medicare Advantage plans.

Career Paths in MCOs

Includes operational roles, care coordination, and utilization review.

Operational Functions of MCOs

Includes tracking data, helping provider networks, controlling quality metrics, payment negotiations, and value-based care.