Insurers use the term “provider” to describe a clinic, hospital, doctor, laboratory, healthcare practitioner, or pharmacy that treats an individual. The “insured” is the owner of the health insurance policy or the person with the health insurance coverage.
Depending on the type of health insurance coverage, either the insured pays costs out of pocket and receives reimbursement, or the insurer makes payments directly to the provider.
In countries without universal healthcare coverage, such as the United States, health insurance is commonly included in employer benefit packages.
In the U.S., the number of people with insurance decreased from 44 million in 2013 to fewer than 28 million in 2016, according to the Kaiser Family Foundation. The researchers put this down to recent changes in legislation.
A Commonwealth Fund 2011 report informed that one-fourth of all U.S. citizens of working age experienced a gap in health insurance coverage. Many people in the survey lost their health insurance when they either became unemployed or changed jobs.
The level of treatment in emergency departments varies significantly depending on what type of health insurance a person has.
There are two main types of health insurance:
Private health insurance: The Centers for Disease Control and Prevention (CDC) say that the U.S. healthcare system relies heavily on private health insurance. In the National Health Interview Survey, researchers found that 65.4 percent of people under the age of 65 years in the U.S. have a type of private health insurance coverage.
Public or government health insurance: In this type of insurance, the state subsidizes healthcare in exchange for a premium. Medicare, Medicaid, the Veteran’s Health Administration, and the Indian Health Service are examples of public health insurance in the U.S.
People also define an insurer by the way they administer their plans and connect with healthcare providers.
Managed care plans: In this type of plan, the insurer will have contracts with a network of healthcare providers to give lower-cost medical care to their policyholders. There will be penalties and additional costs added to out-of-network hospitals and clinics, but they will provide some treatment.
The more expensive the policy, the more flexible it is likely to be with the network of hospitals.
Indemnity, or fee-for-service plans: A fee-for-service plan covers treatment equally among all healthcare providers, allowing the insured to choose their preferred place of treatment. The insurer will typically pay for at least 80 percent of costs on an indemnity plan, while the patient pays the remaining costs as a co-insurance.
Health maintenance organizations (HMOs): These are organizations that provide medical care directly to the insured. The policy will usually have a dedicated primary care physician that will coordinate all necessary care.
HMOs will normally only fund treatment that is referred by this GP and will have negotiated fees for each medical service to minimize costs. This is usually the cheapest type of plan.
Preferred provider organizations (PPOs): A PPO is similar to an indemnity plan, in that they allow the insured to visit any doctor they prefer.
The PPO also has a network of approved providers with which they have negotiated costs.
The insurer will pay less for treatment with out-of-network providers. However, people on a PPO plan can self-refer to specialists without having to visit a primary care physician.
Point-of-service (POS) plans: A POS plan functions as a mix of an HMO and PPO. The insured can choose between coordinating all treatment through a primary care physician, receiving treatment within the insurer’s provider network, or using non-network providers. The type of plan will dictate the progress of treatment.