Managed Care Organizations (MCOs)
Unless otherwise specified, definitions were retrieved on 3/10/2021 from HealthCare.gov and may include clarifying notes by Learn UM Skills to better align with their audience. Definitions may be periodically updated. For the full list of Healthcare.gov definitions, go the aforementioned weblink.
Health Maintenance Organization (HMO)
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
Preferred Provider Organization (PPO)
A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You’ll pay more if you use doctors, providers, and hospitals outside of the network, and you may have higher out-of-pocket costs for services. PPOs give you the choice of getting care from in network or out-of-network providers. If you have a PPO plan, you can visit any doctor without getting a referral.
Point of Service (POS)
A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist. POS plans let you get medical care from both in-network and out-of-network providers. If you have a POS plan, you’ll choose a primary doctor from a list of participating providers. Your primary doctor can refer you to other network providers when needed. If you want to visit an out-of-network provider, you’ll also need a referral and you may pay higher out-of-pocket costs.
Exclusive Provider Organization (EPO)
A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Medi-Cal Managed Care Plan (Low or No Income)
Some people who have Medi-Cal are in a Medi-Cal Managed Care Plan (MCP). These plans have provider networks that include but are not limited to physicians, pharmacies, clinics, labs, and hospitals. A primary care provider is involved in the care of the person.. Medi-Cal covers the basic benefits that all health plans cover. Medi-Cal also covers prescription drugs, vision care, and hearing care.
Excerpts from https://www.dmhc.ca.gov/HealthCareinCalifornia/TypesofPlans.aspx#medical
Medicare Advantage Plans (Seniors or Disabled)
Medicare is a national health insurance program for seniors or those with disabilities. Medicare Advantage is Medicare's managed care program. If an individual joins a Medicare Advantage Plan, all of their Medicare covered services are administered through an HMO or PPO that has a contract with Medicare.
Excerpts from https://www.dmhc.ca.gov/HealthCareinCalifornia/TypesofPlans.aspx#medical
Other Types of Health Coverage
Fee For Service (FFS)
A method in which physicians and other health care providers are paid for each service performed. Examples of services include tests and office visits. Not a health plan.
FFS providers render services and then submit claims for payment that are adjudicated, processed, and paid (or denied) by the specific program's fiscal intermediary.
Insight: Federal health programs, Medicare and Medicaid (aka: Medi-Cal in California) have access to FFS providers. Medicare FFS payment is accepted by most healthcare providers. Conversely, there are few providers who will accept Medicaid FFS payment. This is primarily due to the low reimbursement rate to providers.
Indemnity Plan
Indemnity plans are NOT managed care organizations. These plans are considered "fee-for-service" plans that allow individuals to direct and choose their own health providers. Referrals are not required to visit any physician or hospital that accepts the Indemnity plan. A primary care provider does not need to be involved.
Indemnity plans typically pays a set portion, usually a percentage of total "usual, customary, and reasonable (UCR) "charges after an annual deductible is met. The UCR rate is the amount that healthcare providers in an particular area typically charge for any given service. Monthly premiums for Indemnity plans may be higher than HMO or PPOs.
High Deductible Health Plan (HDHP)
A plan with a higher deductible than a traditional health and managed care plans. The monthly premium is usually lower, but individuals pay more health care costs (deductible) before the health plan starts to pay its share. A high deductible plan (HDHP) can be combined with a health savings account (HSA), allowing individuals to pay for certain medical expenses with money free from federal taxes.
Catastrophic Health Plan
Catastrophic health plans have low monthly premiums and very high deductibles. It is not uncommon to have a deductible over $7000. They may be an affordable way to protect individuals from worst-case scenarios, like getting seriously sick or injured. But individuals pay for most of their routine medical expenses.
Catastrophic health plans is available to people under 30, who are looking for minimal coverage and low monthly premiums, and, to those of any age who are eligible due to financial hardship.