What is a maximum plan dollar limit?

The maximum amount payable by the insurer for covered expenses for the insured and each covered dependent while covered under the health plan.

  • Plans can have a yearly and/or a lifetime maximum dollar limit.
  • The most typical of maximums is a lifetime amount of $1 million per individual.

NOTE:  The Affordable Care Act has removed the ability for insurers to limit plan amounts.

What are managed care plans?

Managed care plans generally provide comprehensive health services to their members, and offer financial incentives for patients to use the providers who belong to the plan. Examples of managed care plans include:

  • Health maintenance organizations (HMOs),
  • Preferred provider organizations (PPOs),
  • Exclusive provider organizations (EPOs), and
  • Point of service plans (POSs).

What is a physician-hospital organization (PHO)?

Alliances between physicians and hospitals to help providers attain market share, improve bargaining power and reduce administrative costs. These entities sell their services to managed care organizations or directly to employers.