Health Plan Operator Modalities: Understand Which is Right for You

Health Plan Modalities Operator: Understand Which is Right for You

The health insurance market is made up of several different types of health insurance providers, and each of these corporations specializes in providing specific services.

Health plans are the best known – like the dental. What usually varies is the work mode and the type of assistance that each of these carriers offer to their members.

The following post will show you the main types of private health service providers and how their working models. Keep following us to learn more and know which option best for your family or company!

Health plan: more traditional mode

This is the most traditional and known method of medical care offered by the operators of health plans . In this mode, the consumer is under a contract that has the right to make use of medical services – such as appointments, tests and procedures.

Each contract has a specific territorial scope and services. All this is set by the health plan mode engaged. This variation of the extension services directly influences the cost of the plans.

Payment of health insurance is done monthly, in advance. The investment plan then offers services to contractors through its network of associates – that defines what doctors, hospital network and procedures that the customer is entitled.

Health plans can be of two types:

  • individual: that the individual hires a plan for her or for her family ;
  • collective: it may be the business when it is intended for employees of a company , or by collective membership when they are hired by classist sectors – such as unions and associations.

medical / dental cooperative: united professionals

Regulated by law 5.7641 / 71, this type of service can be considered a cooperative that consists of a group of people, non-profit, which unite to form a managed care plans.

This cooperative is formed by doctors or exclusively by dentists – in the case of dental cooperatives. The business model can also be marketing health plans.

In addition, cooperatives offer medical services of specialized professionals to hospitals and clinics, when there is the interest of these health centers outsource specific medical services.

The cooperative is the whole relationship between professional and clinic or hospital, from recruitment to benefits issues related to work.

Self-management: management and own driving

In this mode, a legal entity of private law, non-profit operates a health plan intended only for employees, managers, partners, children or adolescents in care, spouse or dependents of the family group to the fourth degree of relationship – be they professional activity or not.

By law, self-management does not have the right to offer health plans for the general public. This operating model is divided basically into three groups:

  • related to public or private entities sponsoring, or founding sponsors;
  • in the form of association or foundation set for a specific professional category and their dependents without any funding;
  • self-management model that can operate health plans, and this function being exercised by their own sector of human resources.

Philanthropy: Profit reversed the free services

Hospital are non-profit entities and operating health plans. The great advantage of this service mode is that you must obtain a charity certificate welfare to exercise it.

This is often the mode of Holy Mercy Homes, associations, congregation of hospitals or charitable societies. Local as well as maintain their bias philanthropist, operating health plans.

Part of the profit from the sale plans is reversed for the maintenance of hospital facilities, payment of medical professionals and maintenance of free consultations and treatments.

Administrator: relationship with health insurance providers

In this type of service, the entity works hiring group plans to offer them to companies wishing to rely on this type of medical care, but choose not to do anything directly with operators.

The benefits administrators are responsible for the entire management plan, such as adjustment values, maintaining the care network and any dealings that needs to be done with the health plan operator.

This business model works by offering all the necessary intermediation activities between the company that wants to hire a public plan and private health plans.

Health insurance: freedom to associate

Insurers do not have their own network. In this mode, the contractor is free to perform any procedure, consultation or examination, and the insurer reimburses this value later.

The deadline for the payment to the member is 30 days after submission of all documents stipulated in the contract. These records show that all had to be made as to medical appointments and procedures.

These choices are free, but must follow the terms of the contract signed between the insurer and the client. Insurers can also act providing medical and hospital services indicated, even if not part of your network of associates.

Thus, the plan provider pays directly to those referenced and get rid of the risk-free choice of plan contractors.

In this case, it is advantageous for the operator – as it can provide reliable professional and advantageous prices to it – and the associated plan, which is sure indication of services and qualified doctors. And that’s important when you do not have preference or knowledge of the subject.

It is always important to note how each type of plan operators offer. For each case there is a more appropriate service – from the values ​​to the type of coverage and network.

Companies, associations, unions or even individuals, alone or with family , must analyze each situation before choosing which plan should be hired. Operators offer a number of services, and are required to cover only what is in the contracts signed between the parties.

What did you think of post? He was helpful? Now you know how to work the operators of health plans and can choose the one that best suits you! Please contact us if you want to take more questions!


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