Out of Pocket Maximum. Once your expenses reach a certain amount in a calendar year, the insurer will pay the reasonable and customary fee in full. Traditional, or indemnity coverage allows patients to manage their own care. Managed care plans typically provide comprehensive health services. They are less expensive for employers and for employees.
Coverage is paid for in advance, monthly or quarterly.
The premium does not vary depending on use of services. Because the financial success of the system is based on limiting use of services, there is a built-in incentive to limit patient care. The primary physician becomes a gatekeeper, referring patients to specialists or other treatments. Gatekeepers can create difficulties for people with a life-challenging condition in several ways. Generally they are not specialists and probably have the financial incentive not to refer patients to specialists.