Traditional Group Health Plans
Historically, Health Maintenance Organizations (“HMOs”) tended to use the term “health plan”, while commercial insurance companies used the term “health insurance”. A health plan can also refer to a subscription-based medical care arrangement offered through HMOs, preferred provider organizations (“PPOs”), or point of service plans (“POS”). These plans are similar to pre-paid dental, pre-paid legal and pre-paid vision plans. Pre-paid health plans typically pay for a fixed number of services (for instance, $300 in preventive care, a certain number of days of hospice or psychiatric care or in a skilled nursing facility; a fixed number of home health visits, a fixed number of spinal manipulation charges, etc.). The services offered are usually at the discretion of a utilization review nurse who is often contracted through the managed care entity providing the subscription health plan. This determination may be made either prior to or after hospital admission (concurrent utilization review). PPO’s normally feature networks with negotiated fees and charges that feature a co-pay (first amount owning paid by insured) and deductibles that may be low or high. They normally do not require referrals or review, unless involving hospitalizations or surgeries, generally referred to as pre-admittance.