Under managed care plans such as HMOs and PPOs, the insurer or health plan pays doctors or hospitals directly for some or all of the cost of the medical services its members receive. For example, physicians may be paid a fixed annual per-member (“capitation”) rate, regardless of how many times the covered individual visits the physician.
A government-sponsored, or public, health insurance program that provides comprehensive publicly funded health insurance coverage to low-income residents who meet specific eligibility criteria. This generally includes those falling below certain income guidelines, or those with disabilities, children, expectant mothers and other individuals with specific healthcare needs.
The Affordable Care Act provided federal funding to expand Medicaid eligibility to those with incomes up to 138% of the federal poverty level (FPL). While the Supreme Court ruled that states could opt out of this Medicaid expansion, as of May 2019, 37 states (including Washington, D.C.) have expanded Medicaid.
Medical loss ratio (MLR)
Refers to a provision of the ACA that requires insurers to spend a specific amount of premium dollars on actual care or activities that improve quality for consumers. For example, a MLR of 80% indicates that every 80 cents per premium $1 is spent on customers’ claims, while the remaining 20 cents can be used on administrative costs. The ACA-set MLRs vary by region, and some states have set additional limits.
A government-sponsored/public health insurance program for adults who are 65 years or older.