What is Commercial Health Insurance?

Commercial health insurance is health insurance provided and administered by non-governmental entities. It covers medical expenses and disability income for the insured.

Understanding Commercial Health Insurance

Commercial health insurance policies are primarily sold by for-profit public and private carriers. Generally, licensed agents and brokers sell plans to the public or group members; however, customers can also purchase directly from the carrier in many instances. These policies vary widely in the amount and types of specific coverage that they provide.

The term commercial distinguishes it from insurance provided by a public or government program, such as Medicaid, Medicare, and State Children's Health Insurance Program (SCHIP). In broad terms, any type of health insurance coverage that isn’t provided or maintained by a government-run program can be considered a commercial type of insurance.

Most commercial health insurance plans are structured as either a Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO). The main difference is that an HMO requires patients to choose one primary care physician, who serves as the central provider and coordinates the care other specialists and healthcare practitioners provide.

Key Takeaways

  • Non-governmental agencies provide and administer what is called commercial health insurance.
  • Two of the most popular commercial health insurance plans are the Preferred Provider Organization (PPO) and Health Maintenance Organization (HMO).
  • Most commercial insurance is provided as group-sponsored insurance, offered by an employer.
  • Although not administered by the government, to a large degree, each state regulates and oversees plan offerings.

Types of Commercial Health Insurance Plans

Commercial health insurance can be categorized according to its renewal provisions and type of medical benefits provided. Commercial policies can be sold individually or as part of a group plan and are offered by public or private companies. Some insurance programs are operated as non-profit entities, often as an affiliated or regional operation of a larger, for-profit enterprise.

Health insurance provided and/or administered by the government is mainly funded through taxes and is geared towards the disadvantaged (e.g., low-income people and disabled persons), military personnel, and federally recognized Native American tribal members.

Health insurance in the commercial market is commonly obtained through an employer. Since the employer typically covers at least a portion of the cost, this is often a cost-effective way for the employee to obtain health coverage. Employers are often able to get attractive rates and terms because they negotiate contracts with insurers and can offer a large number of insurance customers.

Self-employed people and small business owners can buy health insurance coverage, but it is often financially beneficial for them to try and join via a group plan through a professional organization or local group.

The specific details of a commercial insurance plan can vary widely and are determined by the company that offers the plan. State regulatory and legislative bodies also dictate certain aspects of what the plans are required to offer and how they must operate. These laws also establish mandates for how and when insurers must pay invoices, reimburse providers and patients, and the amount of funds the insurer must keep in reserves to have sufficient capital to pay out benefits.