Health Insurance Providers

Commercial Insurance Providers:
- Health insurance can be provided by commercial insurers such as life insurance companies, casualty insurance companies, and monoline companies specializing in medical expense and disability insurance.
- Payment Model: These companies operate on a reimbursement approach allowing policyowners to assign benefit payments directly to healthcare providers through the right of assignment.

Overview:
- Service providers offer benefits to subscribers in exchange for premium payments, which cover services provided by hospitals and physicians.
Blue Cross and Blue Shield:
- Dominant health insurers in the U.S., independently managed but loosely affiliated through the Blue Cross and Blue Shield Association.
- Benefits provided are mainly on a service basis, with direct payments to providers instead of reimbursement.
- Subscribers pay a predetermined monthly fee for services, making it a prepaid plan.
- Most Blue Cross and Blue Shield organizations operate as nonprofits.

Definition:
- HMOs provide comprehensive prepaid health care services and finance these services at their own facilities.
Payment Structure: Subscribers pay a fixed fee for a broad range of services.
Service Delivery: Services rendered by HMO-participating providers.
Capitation: Fixed payment for each HMO member assigned to a physician.
Types of HMOs:
- Closed Panel: Physicians are salaried employees of the HMO and operate out of HMO facilities.
- Open Panel: Physicians work independently and part-time with the HMO.
Preventive Care: HMOs emphasize preventive care with various contracted services for members.

Structure:
- PPOs consist of a network of healthcare providers offering services at discounted rates.
Payment Method: Operate on a fee-for-service basis, providing members a choice of preferred providers.
Cost Implications: Using a non-PPO provider incurs higher out-of-pocket costs for the member.

Definition:
- Outpatient health care consultations or treatments delivered on an outpatient basis.
- Handles a range of services including outpatient surgery and routine physicals.

Purpose:
- Provide insurance for social needs, targeted groups, and encourage economic development.

Overview:
- Launched in 1966 to provide insurance for those 65 and older, and for specific disabilities.
Parts of Medicare:
- Part A: Inpatient hospital and nursing facility services, funded by payroll taxes.
- Part B: Outpatient services, funded by general taxes and premiums.
- Part D: Prescription drug coverage, requires Medicare enrollment.

Eligibility:
- Must be fully insured with required quarters of coverage post-21 years old.
Benefits:
- Available to those unable to work due to disability, with provisions for family members.

Overview:
- Title XIX of the Social Security Act, provides funds for states' medical assistance programs for low-income individuals.
Funding: Jointly funded by federal and state governments, focusing on individuals in need.

Description:
- Federal government health plan for military families providing accident and health coverage.

Overview:
- Managed competition for civilian government employees' health benefits, including fee-for-service plans and HMOs.

Purpose:
- Compensate for employee losses due to work-related incidents, with no time limit on medical expense coverage.

Description:
- Plans administered by external organizations for paperwork and claims processing (ASO).
- Minimum premium plans (MPP) can be purchased to cover excess losses.

Overview:
- Groups employers in similar industries to provide health insurance and other benefits, often self-funded.
- Members must subscribe to join the trust, which holds the master insurance contract.

Definition:
- Type of MET focused on providing health benefits for employees from small employers with a common bond, often self-insured, and tax-exempt.