In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers on a prepaid basis. The US Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status.
The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care. It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
In U.S. health insurance, a preferred provider organization (PPO), sometimes referred to as a participating provider organization or preferred provider option, is a managed care organization of medical doctors, hospitals, and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.
The California insurance commissioner has been an elected executive office position in California since 1991. Prior to that time, the insurance commissioner was appointed by the governor. The officeholder is in charge of the California Department of Insurance.
Highmark is an American non-profit healthcare company and Integrated Delivery Network based in Pittsburgh, Pennsylvania, United States. It is a large individual not-for-profit health insurer in the United States, which operates several for-profit subsidiaries.
Hawaii Medical Service Association (HMSA) is a nonprofit health insurer in the state of Hawaii. HMSA was founded in 1938, is an independent licensee of the Blue Cross Blue Shield Association, and is the largest insurer in the state of Hawaii serving more than 700,000 people.
Blue Cross Blue Shield Association, also known as BCBS, BCBSA, or The Blues, is a United States-based federation with 34 independent and locally-operated BCBSA companies that provide health insurance in the United States to more than 115 million people as of 2022.
Cambia Health Solutions is a nonprofit health care company based in Portland, Oregon. It is the parent company of Regence, a member of the Blue Cross Blue Shield Association operating in Oregon, Idaho, Utah, and Washington; Asuris Northwest Health; BridgeSpan Health; and LifeMap.
Medavie Blue Cross is a not-for-profit Canadian medical care insurance company headquartered in Moncton, New Brunswick.
Premera Blue Cross is a not-for-profit Blue Cross Blue Shield licensed health insurance company based in Mountlake Terrace, Washington, United States. It sells health insurance plans under the Blue Cross license in Washington state except Clark County and under both of the Blue Cross and Blue Shield licenses in Alaska.
In the United States, health insurance helps pay for medical expenses through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include "health coverage", "health care coverage", and "health benefits". In a more technical sense, the term "health insurance" is used to describe any form of insurance providing protection against the costs of medical services. This usage includes both private insurance programs and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like Medicaid and the Children's Health Insurance Program, which both provide assistance to people who cannot afford health coverage.
The Council for Affordable Quality Healthcare, Inc. (CAQH) is a non-profit organization incorporated in California as a mutual benefit corporation. It was first incorporated under the name Coalition for Affordable, Quality Healthcare, Inc., and then renamed the Council for Affordable Quality Healthcare, Inc. on August 8, 2002. It is based in Washington, D.C. Previously a 501(c)(6) tax-exempt organization, CAQH changed its tax status in 2016, although it remains a non-profit.
EmblemHealth is one of the United States' largest nonprofit health plans. It is headquartered at 55 Water Street in Lower Manhattan, New York City. It is a multi-billion-dollar organization with over 3 million members.
Elevance Health, Inc. is an American health insurance provider. Prior to June 2022, Elevance Health was named Anthem, Inc. The company's services include medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans through affiliated companies such as Anthem Blue Cross and Blue Shield, Anthem Blue Cross in California, Wellpoint, and Carelon. It is the largest for-profit managed health care company in the Blue Cross Blue Shield Association. As of 2022, the company had 46.8 million members within its affiliated companies' health plans.
Blue Cross and Blue Shield of Kansas City is an independent licensee of the Blue Cross Blue Shield Association and a not-for-profit health insurance provider with more than one million members. Founded in 1938, Blue KC offers healthcare, dental, life insurance and Medicare coverage. Headquartered in Kansas City, Missouri, the company serves 30 counties in northwest Missouri, and Johnson and Wyandotte counties in Kansas.
BlueCross BlueShield of South Carolina (BlueCross) is an independent licensee of the Blue Cross and Blue Shield Association. BlueCross serves 21.5 million people through private business and government contracts.
Wellmark Blue Cross Blue Shield is a mutual insurance in the United States with more than two million members in Iowa and South Dakota. It is the dominant health insurance in Iowa. It is an independent licensee of the Blue Cross Blue Shield Association. Founded in 1939, Wellmark offers dental and health insurance as well as life insurance. It began participating in the health care exchange for 2017.
CareFirst BlueCross BlueShield is a health insurance provider serving 3.5 million individuals and groups in Maryland and the Washington metropolitan area. It has dual headquarters in Baltimore, Maryland and Washington, D.C. It is a nonprofit organization and an independent licensee of the Blue Cross Blue Shield Association.
GuideWell, formally GuideWell Mutual Holding Corporation, is a mutual insurance holding company primarily focused on health insurance in Florida. It was created in 2013 by a reorganization initiated by Florida Blue, a member company of the Blue Cross Blue Shield Association. By health insurance premiums written, it is 10th largest in providing health insurance in the United States with about $15b in health insurance sales.
$2.0 billion (2008)