Getting to know your Health Plan

 

With all the talk about Health Care Reform you may be hearing a lot of acronyms being thrown around when talking about Health Care (HMO, PPO, POS).  What do they all mean?

Health Maintenance Organization – (HMO): This is a health organization that provides health services to individuals known as subscribers or members.  HMO’s generally contract with a group of doctors or medical practitioners to provided services at an agreed-upon cost.

With a HMO plan you select a Primary Care Physician (PCP) who coordinates your care and refers you to specialists when needed.  Members must rely exclusively on the HMO for all their medical needs to qualify for payment.

Preferred Provider Organization – (PPO): Refers to a select group of hospitals and medical practitioners in a given area who have contracted with an insurer to provide services at a pre-arranged cost.

PPO’s are similar to the HMO, you choose from doctors within your network, but you don’t have to designate one doctor as your PCP.  With a PPO you can go out of your network area, but you will pay a higher cost for services.

• Most services are subject to the deductible
• Certain preventive tests and screenings are not subject to the deductible.  Some preventive tests and screenings are covered at no charge when you receive them from in-network providers.  When you receive them from out-of-network providers, you may pay coinsurance only.
• Most in-network office visits are subject to an office visit copayment.  You will pay an office visit copayment for routine well and sick exams that you receive from in-network providers.  However, you may also receive some tests and services that are subject to the deductible during a routine office visit.

Points of Service - (POS): These plans are a managed care plan that allows the member to receive care from within the network or to go outside the network at a higher cost.

• Members must select a Primary Care Physician (PCP).  Services provided by a participating provider with the proper PCP referral are coved in full after a co-payment is made.  Services that are received from a nonparticipating provider, or a participating provider without the proper PCP referral, are covered at the out-of-network service level.  The member will pay a deductible and coinsurance for this service.

Before coverage starts for certain services, you may have to pay a Deductible, Coinsurance or a Co-pay.

• A deductible is an amount you must pay each calendar year for certain covered services. Once you have paid the deductible you may be covered for these services for the rest of the year, or you may need to pay coinsurance.
• Coinsurance is a percentage of the cost of covered services that you must pay after you have paid your full, annual deductible amount.
  • Under an individual membership, a member is responsible for paying the individual deductible each calendar year
  • A family deductible is met when the combined deductible payments of any covered family members add up to the total family deductible amount.
• Co-pay’s are a set fee that you pay for each service.  There are usually different fees for the type of service you receive.  You might pay $20 for preventive office visits and $30 for specialty office visits.  (Check with your plan administrator for co-pay fees).

When choosing a health plan you need to know what you’re looking for in order to make the most out of your health care dollars.

Here are 6 things to consider when choosing a plan.

1. Affordability – Look at everything from the overall cost of the plan to deductibles to coinsurance & co-pays.
2. Coverage – Finding out what’s covered and what’s not covered should be a key concern.  (If you are planning on starting a family you will want to make sure you have maternity benefits).
3. Convenience – How close is your in-network doctor, hospitals, medical centers?
4. Support Tools – What kind of information does their website provide?  Can you find a list of network doctors?  Do they tell you what you plan covers?
5. Flexibility to Providers – How wide is the plan’s network of medical providers?  Do any of your doctors/specialists participate in the plan you’re interested in?  Can you still go to your favorite hospital?
6. Options for Savings Accounts – Is the plan qualified for a Health Savings Account (HSA) or Flexible Spending Account (FSA)?

Contact us for more information about group health insurance.