Health insurance plans

Health insurance plans

Health insurance plans are usually described as either indemnity (fee-for-service) or managed care. These types of plans differ in important ways that are described below. With any health plan, however, there is a basic premium, which is how much you or your employer pay, usually monthly, to buy health insurance coverage. In addition, there are often other payments you must make, which will vary by plan. In considering any plan, you should try to figure out its total cost to you and your family, especially if someone in the family has a chronic or serious health condition.

Indemnity and managed care plans differ in their basic approach. Put broadly, the major differences concern choice of providers, out-of-pocket costs for covered services, and how bills are paid. Usually, indemnity plans offer more choice of doctors (including specialists, such as cardiologists and surgeons), hospitals, and other health care providers than managed care plans. Indemnity plans pay their share of the costs of a service only after they receive a bill.

Managed care plans have agreements with certain doctors, hospitals, and health care providers to give a range of services to plan members at reduced cost. In general, you will have less paperwork and lower out-of-pocket costs if you select a managed care type plan and a broader choice of health care providers if you select an indemnity-type plan.

Over time, the distinctions between these kinds of plans have begun to blur as health plans compete for your business. Some indemnity plans offer managed care-type options, and some managed care plans offer members the opportunity to use providers who are "outside" the plan. This makes it even more important for you to understand how your health plan works.

Besides indemnity plans, there are basically three types of managed care plans: PPOs, HMOs, and POS plans.


Indemnity Plan
Also known as traditional or fee-for-service plans . allow you to choose any doctor or hospital you want. In return, you pay an annual deductible, then a percentage of your medical bill. Although these plans offer the greatest freedom to select any doctor, they are usually the most expensive option available. You or they send the bill to the insurance company, which pays part of it. Usually, you have a deductible. such as $200. to pay each year before the insurer starts paying.

Once you meet the deductible, most indemnity plans pay a percentage of what they consider the "Usual and Customary" charge for covered services. The insurer generally pays 80 percent of the Usual and Customary costs and you pay the other 20 percent, which is known as coinsurance. If the provider charges more than the Usual and Customary rates, you will have to pay both the coinsurance and the difference.

The plan will pay for charges for medical tests and prescriptions as well as from doctors and hospitals. It may not pay for some preventive care, like checkups.


Managed Care
Preferred Provider Organization (PPO). A PPO combine elements of indemnity and managed care plans. Each time you need care, you choose among doctors who belong to the PPO network or any non-network doctor. You pay less when you use the network's "preferred providers." However, you can see any doctor any time you wish, usually without getting an okay from the plan first. If you choose not to use the plan's preferred providers, you will probably have to pay more for care .

If you go to a doctor within the PPO network, you will pay a copayment (a set amount you pay for certain services. say $10 for a doctor or $5 for a prescription). Your coinsurance will be based on lower charges for PPO members.

If you choose to go outside the network, you will have to meet the deductible and pay coinsurance based on higher charges. In addition, you may have to pay the difference between what the provider charges and what the plan will pay.

Health Maintenance Organization (HMO). HMOs require that you pay a small, set copayment when you use the plan's HMO doctors. You generally don't have to pay a deductible in an HMO. You usually select a primary care physician who manages all of your health care and serves as a gatekeeper for specialty care. If you go to doctors who are not in the HMO, you pay the full cost of the care (unless it's an emergency situation). Most HMOs are relatively inexpensive, offer preventive care services, and have special programs for disease management

There are many kinds of HMOs. If doctors are employees of the health plan and you visit them at central medical offices or clinics, it is a staff or group model HMO. Other HMOs contract with physician groups or individual doctors who have private offices. These are called individual practice associations (IPAs) or networks.

HMOs will give you a list of doctors from which to choose a primary care doctor. This doctor coordinates your care, which means that generally you must contact him or her to be referred to a specialist.

With some HMOs, you will pay nothing when you visit doctors. With other HMOs there may be a copayment, like $5 or $10, for various services.

Point-of-Service (POS) Plan. Many HMOs offer an indemnity-type option known as a POS plan. POS plans or Open Access HMOs add an out-of-network benefit to HMOs. Like HMOs, you select a primary care physician who manages all of your care and is responsible for referring you to plan specialists.

In a POS plan however, you have the option of going outside the HMO network (although you¹ll pay more for care received outside of the network).


The biggest advantage of conventional medical insurance is the flexibility it provides employees. Also known as indemnity coverage, conventional health insurance allows individuals to visit any physician or medical facility they want and receive coverage for any treatment covered under the policy. program members can go to any specialist without a referral, and the medical care insurance company has no say as to whether the visit is necessary. Unfortunately for people who prefer this flexibility, few employers offer conventional health insurance programmes these days.

Cost is the main reason these programmes are disappearing. Because there are few oversight or cost-saving measures, premiums for conventional prescription insurance tend to be higher than other programs. Conventional medical insurance also carries more out-of-pocket expense, since most plans require costly deductibles before coverage kicks in, and co-insurance that leaves the insured responsible between 5% and 20% of each charge.

health & medical organizations

medical care insurance organizations health maintenance organization were the first alternatives to conventional prescription insurance. By creating a network of physicians and infirmarys and implementing cost-saving measures, health & medical organizationss are able to control costs better than other Plans. Overall, HMO premiums are the lowest of any type of service.

Compare Multiple Organizations

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Payroll Plans

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Business Phone Systems

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However, health and medical organizationss are also the least flexible type of prescription insurance programme. They require members to choose a primary care doctor who performs basic health checkups and approves visits to other doctors. These plans generally only cover the expense of visits to doctors and medical facilitys that are part of the network. Visits to nonparticipating medical practitioners must be paid directly by the employee.

This gatekeeper system represents both the best and the worst of health maintenance organizations. While this structure helps minimize costs for employers, it can be unpopular with employees who currently use doctors outside the health maintenance organization network, since they must switch medical practitioners to receive coverage. Also, employees who want more control over their medical care can find it annoying to jump through the gatekeeper hoop to see specialists.

PPO

Preferred provider organizations, or PPOs, are now the most popular choice for employer-sponsored health care. A PPO is a collection of physicians and medical facilitys that agree to provide health care at a reduced cost to PPO members. With this setup, health insurance services can limit health care costs without the restrictions of an HMO.

Most PPOs are similar to conventional medical insurance policies, except that PPOs have two different levels of coverage. For visits to doctors and medical facilitys that are affiliated with the PPO, patients pay a low deductible and little or no co-insurance. But visits to doctors and infirmarys outside the network require higher payments from the patient.

This structure is designed to encourage PPO members to use specific doctors and infirmarys that have been designated by the organization as preferred providers. These physicians and hospitals agree to provide health care to PPO members at lower rates, which allows the PPO to reduce overall medical care insurance costs.

POS

Also known as open-ended health & medical organizationss, point of service (POS) programs combine elements of both health & medical organizationss and PPOs. As with an health & medical organizations, members choose a primary care physician who will provide referrals when needed. But they are also free to visit out-of-network providers without a referral, and at least some of the expenses will be covered. However, members who use services outside the network must pay more than they would for in-network services. This increased cost typically involves deductibles and coinsurance, much like conventional fee-for-service services.

POS services are popular with some employees because they provide much of the cost savings of health and medical organizationss, but still include some coverage if the member wants to choose a specific doctor.

Finally, a new type of health insurance service that is rapidly gaining popularity is the consumer-driven health insurance policy.

 


The biggest advantage of conventional medical insurance is the flexibility it provides employees. Also known as indemnity coverage, conventional health insurance allows individuals to visit any physician or medical facility they want and receive coverage for any treatment covered under the policy. program members can go to any specialist without a referral, and the medical care insurance company has no say as to whether the visit is necessary. Unfortunately for people who prefer this flexibility, few employers offer conventional health insurance programmes these days.

Cost is the main reason these programmes are disappearing. Because there are few oversight or cost-saving measures, premiums for conventional prescription insurance tend to be higher than other programs. Conventional medical insurance also carries more out-of-pocket expense, since most plans require costly deductibles before coverage kicks in, and co-insurance that leaves the insured responsible between 5% and 20% of each charge.

health & medical organizations

medical care insurance organizations health maintenance organization were the first alternatives to conventional prescription insurance. By creating a network of physicians and infirmarys and implementing cost-saving measures, health & medical organizationss are able to control costs better than other Plans. Overall, HMO premiums are the lowest of any type of service.

Compare Multiple Organizations

BuyerZone offers a free comparison tool to review products, services, and in-depth profiles of several companies. You can instantly research:

Payroll Plans

PEO Services

Business Phone Systems

Commercial Cleaning

And more…

However, health and medical organizationss are also the least flexible type of prescription insurance programme. They require members to choose a primary care doctor who performs basic health checkups and approves visits to other doctors. These plans generally only cover the expense of visits to doctors and medical facilitys that are part of the network. Visits to nonparticipating medical practitioners must be paid directly by the employee.

This gatekeeper system represents both the best and the worst of health maintenance organizations. While this structure helps minimize costs for employers, it can be unpopular with employees who currently use doctors outside the health maintenance organization network, since they must switch medical practitioners to receive coverage. Also, employees who want more control over their medical care can find it annoying to jump through the gatekeeper hoop to see specialists.

PPO

Preferred provider organizations, or PPOs, are now the most popular choice for employer-sponsored health care. A PPO is a collection of physicians and medical facilitys that agree to provide health care at a reduced cost to PPO members. With this setup, health insurance services can limit health care costs without the restrictions of an HMO.

Most PPOs are similar to conventional medical insurance policies, except that PPOs have two different levels of coverage. For visits to doctors and medical facilitys that are affiliated with the PPO, patients pay a low deductible and little or no co-insurance. But visits to doctors and infirmarys outside the network require higher payments from the patient.

This structure is designed to encourage PPO members to use specific doctors and infirmarys that have been designated by the organization as preferred providers. These physicians and hospitals agree to provide health care to PPO members at lower rates, which allows the PPO to reduce overall medical care insurance costs.

POS

Also known as open-ended health & medical organizationss, point of service (POS) programs combine elements of both health & medical organizationss and PPOs. As with an health & medical organizations, members choose a primary care physician who will provide referrals when needed. But they are also free to visit out-of-network providers without a referral, and at least some of the expenses will be covered. However, members who use services outside the network must pay more than they would for in-network services. This increased cost typically involves deductibles and coinsurance, much like conventional fee-for-service services.

POS services are popular with some employees because they provide much of the cost savings of health and medical organizationss, but still include some coverage if the member wants to choose a specific doctor.

Finally, a new type of health insurance service that is rapidly gaining popularity is the consumer-driven health insurance policy.

 

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