Health Insurance is a type of insurance whereby the insurer pays the medical costs of the insured if the insured becomes sick due to covered causes, or due to accidents. The insurer may be a private organization or a government agency. Market based health care systems such as that used in the United States rely on private medical insurance.
Individual and family health insurance plans are usually described as either "indemnity" or "managed-care" plans. Put broadly, the major differences concern choice of healthcare providers, out-of-pocket costs and how bills are paid. Typically, indemnity plans offer a broader selection of healthcare providers than managed care plans. Indemnity plans pay their share of the costs for covered services only after they receive a bill (which means that you may have to pay up front and then obtain reimbursement from your health insurance company).
There are several different types of managed-care health insurance plans. These include HMO, PPO, and POS plans. Managed-care plans typically make use of healthcare provider networks. Healthcare providers within a network agree to perform services for managed-care plan patients at pre-negotiated rates and will usually submit the claim to the insurance company for you. In general, you'll have less paperwork and lower out-of-pocket costs with a managed care health insurance plan and a broader choice of healthcare providers with an indemnity plan.
What is a Health Maintenance Organization (HMO)
A health maintenance organization (HMO) is a prepaid health plan. As an HMO member, you pay a monthly premium. In exchange, the HMO provides maintenance care for you and your family, including doctors' visits, hospital stays, emergency care, surgery, lab tests, x-rays, and therapy.
A health maintenance organization arranges for this care either directly in its own group practice and/or through doctors and other health care professionals under contract. Usually, your choices of therapy, diagnosis, doctors and hospitals are limited to those that have agreements with the HMO to provide care. However, exceptions are made in emergencies or when obviously medically necessary.
Because HMOs receive a fixed fee for your covered medical care, it is theoretically in their interest to make sure you get basic health care for simple problems before they become serious. Often, the HMO shifts the financial risk for your care to the doctors they contract with by paying a fixed monthly payment for each patient under the doctors care. This is called "capitation". Any treatment a patient receives under this system decreases the HMO's or the doctor's income. This replaces a possible incentive under a fee-for-service system to provide unnecessary care, with an incentive to do too little. HMO coverage typically includes preventive and early detection care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. The range of services covered vary in HMOs. Some services, such as outpatient mental health care, often are provided only on a limited basis, and more costly forms of care, diagnosis, or treatment may not be not covered.
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