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Frequently
Asked Questions About Individual Health Care |
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What
types of health plans are available to me?
Where
are the other health plans I am familiar with?
What
is a PPO?
What
is an HMO?
What
is an MSA?
What
is a POS?
What
is an Indemnity Plan?
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What
types of health plans are available to me? |
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Health
insurance plans usually are described as either indemnity (fee-for-service)
or managed care. Indemnity and managed care plans differ in their basic
approach. Put broadly, the major differences concern choice of providers,
out-of-pocket costs for covered services, and how bills are paid. Usually,
indemnity plans offer more choice of doctors (including specialists,
such as cardiologists and surgeons), hospitals, and other health care
providers than managed care plans.
Indemnity
plans pay their share of the costs of a service only after they receive
a bill. Managed care plans have agreements with certain doctors, hospitals,
and health care providers to give a range of services to plan members
at reduced cost. In general, you will have less paperwork and lower
out-of-pocket costs if you select a managed care-type plan and a broader
choice of health care providers if you select an indemnity-type plan.
Besides
indemnity plans, there are three basic types of managed care plans:
PPOs, HMOs, and POS plans.
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Where
are the other health plans I am familiar with? |
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Not all
health plans sell health insurance directly to individuals and families.
Many, like Aetna and Cigna, provide insurance predominately through
employers.
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What
is a PPO? |
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A PPO is
a 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.
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.
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What is an HMO? |
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An HMO
is a 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 nothing when you visit in-network doctors.
With other HMOs there may be a small copayment for the visit or service.
• 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.
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What
is an MSA? |
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An
MSA is a Medical Savings Account. It is 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.
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What
is a POS? |
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POS is
a Point-of-Service 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.
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What
is an Indemnity Plan? |
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An
indemnity plan is commonly known as a 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.
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Copyright
© 2003 Total Insurance Network, All Rights Reserved.
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