HMO/PPO/MSA/POS/Indemnity
Plan
If you have a question, we hope that the following questions and answers will help.
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What is the difference between and in-network and an out-of-network medical provider?
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Can I buy health insurance for less if I go directly to the insurance company?
Q) What is the best health plan for me?
Choosing between health plans is not as easy as it once was. Although there is no one "best" plan, there are some plans that will be better than others for you and your family's health needs.
Plans differ in how much you have to pay and how easy it is to get the services you need. Although no plan will pay for all the costs associated with your medical care, some plans will cover more than others.
With any health plan you will pay a basic premium, usually monthly, to buy the health insurance coverage. In addition, there are often other payments you must make. These payments will vary by plan but essentially are deductibles, coinsurance, and copayments.
Q) How do I compare health plans?
Here’s a list of some key question to consider when choosing a health plan:
How much will it cost me on a monthly basis?
Are there deductibles I must pay before the insurance begins to help cover my costs? After I have met your deductible, what part of my costs are paid by the plan?
What doctors, hospitals, and other medical providers are part of the plan? Are there enough of the kinds of doctors I want to see?
Where will I go for care? Are these places near where I work or live?
If I use doctors outside a plan's network, how much more will I pay to get care?
Are there any limits to how much I must pay in case of major illness? What about limits and deductibles for certain types of care such as surgery or maternity?
Q) What is an HMO / PPO / MSA / POS / Indemnity Plan?
Most health insurance companies offer several types of programs with many variations in deductibles, copayments and covered services. Review the details of any specific plan very carefully before purchasing to ensure it will meet you and your family's specific needs.
HMO (Health Maintenance Organization)
As a member of an HMO, you select a primary care physician from a list of doctors in that HMO's network. Your primary care physician will be the first medical provider you call or see for a medical condition. He or she will make any needed referrals to a medical specialist. Typically, these specialists will be part of the HMO network.
If you obtain care without your primary care physician's referral or obtain care from a non-network member, you may be responsible for paying the entire bill. (with exceptions for emergency care)
With some HMOs, you pay a small copayment (but they are getting larger) when you visit in-network doctors.
With most HMOs you will not be responsible for paying a deductible.
If you join an HMO, you should find that you have few out-of-pocket expenses for medical care-- as long as you use doctors or hospitals that are part of the HMO.
PPO (Preferred Provider Organization)
As a member of a PPO, you can use the doctors and hospitals within the PPO network or go outside of the network for care. You do not need a referral to see a specialist.
If you obtain care from a medical provider outside of the PPO network, you will pay more for the service. For example, a PPO might pay 90 percent of the cost for a visit with an in-network doctor but only 70 percent of the cost for a visit to a non-network doctor.
You will typically pay a copayment for each visit/service. These copayments are typically higher than an HMO copayment but not always.
You will usually be responsible for paying an annual deductible.
You will usually have some expense after satisfying your deductible, called coinsurance. It could be 0%., 10%, 20%, 25%, or 50% until a certain out of pocket maximum has been reached, usually $1,000 - $2,000, then the insurance usually covers 100% of any additional bills for the rest of that calendar year.
If you join a PPO, you should find you have more flexibility than with an HMO, but your total out of pocket costs are likely to be somewhat higher.
MSA (Medical Savings Account)
A tax-advantaged personal savings account used in conjunction with a high deductible health policy. Individuals can contribute money to this account on a pre-tax basis to set aside money for qualified medical care and expenses, including annual deductibles and copayments. This is usually only available to self-employed or independent contractors (people who receive a 1099 instead of a W-2).
Point-of-Service (POS) Plan
A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs). You can decide whether to go to a network provider and pay a flat dollar or to an out-of-network provider and pay a deductible and/or a coinsurance charge. These are more likely to be available in group rather than individual plans.
Indemnity Plan (also called Fee for Service or Traditional Plan)
If you select an Indemnity plan you have the freedom to visit any medical provider. You do not need referrals or authorizations; however, some plans may require you to precertify for certain procedures.
Most indemnity plans require you to pay a deductible. After you have paid your deductible, indemnity policies typically pay a percentage of "usual and customary" charges for covered services; often the insurance company pays 80% and you pay 20%. Most plans have an annual out of pocket maximum and once you've reached this they will pay 100% of all "usual and customary" charges for covered services.
Many health insurance companies have moved away from indemnity plans and are instead offering managed care plans such as HMOs and PPOs. You may have few or no indemnity plan choices in your area. An advantage of the PPO is that there is no "balance billing". Balance billing is the difference between "reasonable and customary" and what the doctor actually charges. Since in a PPO they have an agreement with the doctor, the PPO reprices the charges and there is no balance to bill, instead you actually get a discount even if the charge will not be covered because you have not met your deductible.
A copayment is a fixed dollar amount or a percentage that you pay for each visit/service. For example, with some plans you may pay a fixed amount such as $5 or $10 per visit. Other plans will charge you a percentage of the total fee for the visit. So if your copayment is 10% and the doctor visit was $200, you would pay 10% which, in this case, would be $20.
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A deductible is the amount of annual medical expenses that a health plan member must pay before the plan will begin to cover expenses. For example, if your plan has a $500 deductible, you will pay the first $500 of your medical expenses before your health plan begins paying the expenses. Only expenses for covered services apply towards the deductible. For example, if you paid $100 for a visit to a chiropractor but the plan does not consider chiropractic care a covered expense, then the $100 will not apply toward your annual deductible.
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Q) What is the difference between an in-network and an out-of-network medical provider?
An in-network medical provider is within the approved network of providers for a particular health plan. Out-of-network providers are not on the list. If you visit a doctor within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network doctor. In many cases, the insurance company will not pay anything for services your receive from outside their network; however, there are exception to this.
As a general rule, HMOs tend to have smaller provider networks than PPOs. In HMO and PPO plans, referrals to specialists will be to doctors within the network. Indemnity plans typically do not have networks; you go to whatever doctor you want.
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Q) What are my options for making my first payment?
Most plans require that a deposit accompany your application. You can pay this deposit to the health insurance company you have selected by check when you send in your printed application. If you are not approved for coverage by that company, your money will be refunded by the insurance company. Once accepted as a plan member, all bills will be sent from the health insurance company and you will pay them via the choices offered by that company.
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Q) Can I buy health insurance for less if I buy directly from the insurance company?
No. Insurance companies charge the same premium (Premiums are filed with the state in which the plan is offered) whether the plan is purchased directly from the company, through a broker, or on-line.
Q) What do you mean by guaranteed best price?
For the plans presented here we can provide the lowest price available anywhere, since all of the prices are filed with the state in which the plan is offered and by law cannot be discounted or any fees added that have not been included in the filed premium.
Q) Where are the other health plans I am familiar with?
Not all health plans sell health insurance directly to individuals and families. Many, like Aetna and Cigna, provide insurance predominately through employers (group plans).
Q) Do you offer health insurance for businesses?
Yes. We can offer quotes for small businesses from 1 (in some states) to 100 people (Group Plans) either directly or through affiliates. You will have to submit tax information, business license information, and other information to verify that you are an eligible business.