Plan options

Mar 25, 2019

Last modified on October 31st, 2023 at 7:47 am

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Whether you choose a MARKET PLACE or PRIVATE HEALTH EXCHANGE you can select from four different categories of provision. They are: –

You may also elect for:

These categories do not reflect the quality of the service provided, but they may reflect the choices available and the administrative simplicity in accessing specialist provision.

Health Maintenance Organization (HMO)

An HMO delivers all health services through a network of healthcare providers and facilities. With an HMO, you may have:

  • Limited freedom to choose your health care providers. [you may of course select an HMO of which you’re your regular primary care doctor is a member]
  • The least amount of paperwork compared to other plans.
  • A primary care physician to manage your care and refer you to specialists when you need one, to ensure that the care is covered by the health plan. Most HMOs will require a referral before you can see a specialist.

What doctors you can see: Any in your HMO’s network. If you see a doctor who is not in the network, you will have to pay the full bill yourself. Emergency services at an out-of-network hospital will be covered at ‘in-network’ rates, but non-participating doctors who treat you in the hospital, can bill you.

What you pay:

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: Your plan may require you to pay the amount of a deductible before it covers care beyond preventive services.
  • Copays and/or co-insurance for each type of care.

Paperwork involved. No claim forms.

Considerations

  • So far as possible stay within the network defined by your plan
  • Consult your Primary care physician before seeking specialist consultation
  • Attend ER only in emergency situations

Preferred Provider Organization (PPO)

 With a PPO, you may have: 

  • greater freedom to choose your health care providers. You do not have to get a referral from a primary care physician to see a specialist.
  • Higher out-of-pocket costs if you see out-of-network providers.
  • More paperwork than with other plans if you see out-of-network providers.

What doctors you can see: Any in the PPO’s network. You can see out-of-network doctors, but you can expect to pay more.

What you pay:

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: Some PPOs may have a deductible. You will probably have to pay a higher deductible if you see an out-of-network doctor.
  • Copay or coinsurance for each type of service
  • Other costs: If your doctor charges more than others in the area do, you may have to pay the excess after your insurer pays its share.
  •   Paperwork involved. There’s little to no paperwork with a PPO if you see an in-network doctor. If you use an out-of-network provider, you’ll have to pay the provider. Then you have to file a claim to get the PPO plan to pay you back.

Considerations

  • Your monthly premium will be higher but you have more flexibility in your choice of provider
  • You do not need a referral to see a specialist

Point-of-Service Plan (POS)

APOS plan blends features of an HMO with a PPO. With POS plan, you may have:

  • More freedom to choose your health care providers than you would in an HMO
  • A moderate amount of paperwork if you see out-of-network providers
  • A primary care doctor who coordinates your care and who refers you to specialists

What doctors you can see?  You can see any in-network provider your primary care doctor refers you to. You can see out-of-network doctors, but you can expect to pay more.

What you pay:

  • Premium: This is the cost you pay each month for insurance
  • Deductible: Your plan may require you to pay the amount of a deductible before it covers care beyond preventive services
  • Copays or coinsurance for each type of service used

Considerations

If you travel or are frequently out of state POS may offer you the best coverage.

  • Your monthly premium may be higher but your choices of provider is greater
  • . You may pay a higher deductible if you see an out-of-network provider.
  • Paperwork involved. If you go out-of-network, you will have to pay your medical bill. Then you submit a claim to your insurer for reimbursement

·       Exclusive Provider Organization

  • A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency). EPOs function much like a PPO with a much lower cost. This lower cost is possible because EPO’s limit coverage to in-network providers and facilities. Like a PPO, you may select where you access and receive care; from general practitioners, to specialists, to outpatient facilities. Copayments and deductibles are similar to those found in PPO plans (even in-network coinsurance or cost-sharing amounts), but there is no out-of-network coverage. The insured is fully responsible for costs of care delivered by an out-of-network provider.
  • Considerations
  • The lower premium cost of these plans makes them an attractive proposition for those with low demands on healthcare services.  It remains the insureds responsibility to choose a policy that adequately meets their needs from an approved insurer.

High-Deductible Health Plan with or without a Health Savings Account

You may be able to pay less for your insurance with a High-Deductible Health Plan. An HDHP, may be used with any of these types of health plans: HMO, PPO, or POS

These HDHP plans offer a balance between premiums and deductibles. 

Simply put, the more you are prepared to pay in ‘deductibles’ (your share) the lower the premium you will have to pay the insurer for the benefit (their share).  If you exceed your deductibles you will pay your agreed co-shares and co-insurances until you reach your ‘maximum out of pocket. ’Thereafter your insurance plan pays 100% of your healthcare expenses.

  • If you have no major claims on your insurance plan you will benefit significantly from the lower premiums.  In the worst case you spend more on co-share and co-insurance.  You still receive the same overall healthcare protection
  • A health savings account (HSA) to help pay for your care. The money you put in an HSA is not taxed and can be used tax-free on eligible medical expenses.

Considerations

With an HDHP, your out-of-pocket spending is capped. For instance, if you have insurance only for yourself, the most you have to spend in a year is about $6,450, not including premiums. If our insurance plan is for your family, the most you have to pay in a year is about $12,900 without premiums. The totals include your deductible. If you reach this amount, the plan pays 100% of your care.

Paperwork involved. The amount of paperwork varies, depending on whether you get care from a PPO, HMO, or POS plan. Keep all your receipts so you know when you’ve met your deductible.

What doctors you can see. This varies depending on the type of plan — HMO, POS, or PPO

What you pay.

  • Premium: An HDHP has the lowest premium compared to other plans.Deductible: The deductible is high – in 2015, deductibles for individual health plans range between $1,300 and $6,450 for one person or between $2,600 and $12,900 for a family. Like with HMOs and PPOs, your preventive care is free even if you haven’t met the deductible.
  • Copays or coinsurance:  You must review your plans benefits carefully to learn what you will pay when you go for medical care.

With an HDHP, your out-of-pocket spending is capped. For instance, if you have insurance only for yourself, the most you have to spend in a year is about $6,450, not including premiums. If your insurance plan is for your family, the most you have to pay in a year is about $12,900 including co-shares and co-insurances but excluding premiums.  The totals include your deductible. If you reach this amount, the plan pays 100% of your care.

Paperwork involved. The amount of paperwork varies, depending on whether you get care from a PPO, HMO, or POS plan. Keep all your receipts so you know when you’ve met your deductible.

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