Health care insurance can be confusing. A good place to begin learning more about the issues behind health care insurance is with the basic types of health insurance. For those who are new to it, it can be downright unfathomable.
There are, generally, two types of health care insurance: indemnity and managed care which is often referred to as HMO.
Indemnity Health Care
Indemnity health care insurance is also known as “fee-for-service”. This type of insurance will offer the most flexibility because it allows you to pick your own doctor, clinics, hospitals, etc. The downside is that it will cost a good deal more than the managed types of health care plans. These added costs may be reflected in the premiums that you pay, but they will certainly be reflected in the out of pocket costs that you have to pay when you go for care. For many people, the out of pocket costs can make indemnity health insurance a non-option.
In addition to much higher out of pocket cost you will also be required to pay an annual deductible, which can range from a few hundred dollars to a few thousand dollars. This amount must be paid before the insurance will even begin to pay.
Once the annual deductible has been paid into your account, the insurance company will then pay a portion of what is owed. You will normally have to make a co-payment of around twenty percent or so, and the insurance company will then pay its eighty percent. If the doctor or other health professional charges high rates to begin with, you may end up paying a higher rate because the insurance company will normally pay only what it considers to be “usual and customary” fees for the service.
Generally, indemnity health care insurance covers only illness or accidents, and does not pay for preventive care such as flu shots or birth control medication or devices. Depending on your policy, it may or may not pay for prescription drugs or psychotherapy.
Managed Health Care
Managed care can be thought of as the opposite of indemnity care. With a health maintenance organization (HMO), your deductibles are often smaller than with other plans. In some cases, there may not be any deductibles at all. Co-payments are almost always fixed and kept low. Most preventive care, drugs, and mental health treatments are covered but you should always check on this.
The downside to managed care health insurance is that you must choose from doctors, hospitals, and other health care providers who have contracts with your HMO. In other words, you cannot simply go to whomever you want. Also, you are limited to receive only those medical services authorized by the plan that you have. If you use non-authorized providers or receive non-authorized care, your insurance will not pay any portion of the bills.
Health Maintenance Organization (HMO)
HMOs have become increasingly more common in the last decade. Again, the insured pays a premium which makes him/her a member of the HMO. As a member of the group the member is entitled to visit any of the doctors who are part of the group. These doctors may all work together in an HMO facility or may work in individual clinics as part of a group of doctors under contract to the HMO. Members may have to pay what is called co-pay when they visit the doctor. No paperwork is necessary to validate the claims of an HMO member; however, members may wait longer for non-emergency appointments than they would with a fee for service insurance program. An HMO generally requires its members to have a primary care physician who then refers the member to a specialist if needed.
Preferred Provide Organizations (PPO)
The PPO, a blend of the fee for service model and the HMO model, is a type of health insurance growing in popularity. As with an HMO there is a network of doctors from which the insured chooses his/her physician. This physician is responsible for designating the need for specialized care. A co-payment will be required when an office or hospital visit is made. There will also be a deductible and medical expenses will be divided at an agreed upon scale between the insured and the insurance company operating the PPO. A person may choose to use a doctor who is outside of the network. Expenses incurred for medical care outside the network will make the patient’s share higher.
Because many people did not like these restrictions, managed care has begun to evolve to include hybrid plans that blend HMOs with some of the features of indemnity health care coverage.
One example is the Point-of-Service plan. If you are under a point-of-service plan (POS), you can keep your overall costs low by using a network of doctors and hospitals that have contracts with your insurer. If you decide to go outside the network that has been set up for the plan, you will have to pay an added deductible as well as higher co-payments for the services rendered.
Please collect as many quotes as possible in order to compare services and rates. This is a free way to learn a lot about all of your options.