| |
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. |
 |
|
|
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 .
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.
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 youčll pay more for care received outside of the network).
|
