Medical
Health Maintenance Organizations (HMOs)
- Routine office visits;
- Diagnostic tests;
- Hospital care;
- Surgery;
- Emergency care; and
- Preventive service
Preferred Provider Organizations (PPOs)
Fee-for-Service or Traditional Indemnity Plans
Point of Service (POS)
High Deductible Health Plans (HDHPs) and Health Savings Accounts (HSAs)
- A higher annual deductible than typical health plans; and
- A maximum limit on the sum of the annual deductible and out-of-pocket medical expenses that must be paid for covered expenses. Out-of-pocket expenses include co-payments and other amounts but do not include premiums.
- Survey definitions from:
- The National Compensation Survey definitions (BLS),
- The Medical Expenditure Panel Survey definitions (AHRQ), and
- The National Employer Health Insurance Survey definitions (NCHS)
- Definitions from other Federal agencies and surveys, such as:
- The Current Population Survey (BLS/Census)
- ERISA-related definitions (from PWBA)
- Glossaries and informational papers from websites such as:
- OPM’s Federal Employees Health Benefits, makes, the current limitWithoutPlans (glossary and specific plan booklets)
- Blue Cross / Blue Shield
- The National Center for Policy Analysis, and The Health Insurance Association of America.
- Publications such as:
- Employee Benefit Plans: A Glossary of Terms, Ninth Edition 1997, Judith A. Sankey - editor, International Foundation of Employee Benefit Plans.
- "Fundamentals of Employee Benefit Programs, Fourth addition"
- "Managed Care Plans and Managed Care Features: Data from the EBS to the NCS", Cathy A. Baker and Iris S. Díaz, Compensation and Working Conditions, Spring 2001
- EBRI Notes Vol. 16, no. 7, July 1995
- HIAA Source Book
Self Insured VS Fully Insured
Fully insured health plans are typically group health insurance plans in which an employer or company pays the health insurance premiums for coverage. Insurance companies that provide the group health insurance plan for an employer set the premium rates each year. Fully insured plans have many characteristics that make them different from other types of health insurance plans. These include pooling, risks, premiums, and employer size.
Self-insured plans, unlike fully insured plans, are generally designed in which the sponsor retains the risk associated with paying covered health expenses, rather than paying a premium and transferring the risk to an insurance company. Some sponsors retain the risk for a subset of the benefits, but transfer the risk for the remaining benefits to health insurers – that is, they finance the plan’s benefits using a mixture of self-insurance and insurance. Self-insurance is more common among larger sponsors, mainly because the health expenses of larger groups are more predictable, and therefore larger sponsors face less risk.