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While health plans have many different features and limitations, most of
them have the same basics. This page summarizes some of those
features to help you understand what you are reading. If you
have questions about ANY policy you are looking at, use one of the
buttons in the top right corner of this page to contact us. We
will be glad to answer your questions whether you are a client or not.
HMO - Health Maintenance Organization -- this type of plan is
based on a subscription fee paid by the member, which essentially pays
for all health care services needed as provided in the specific network.
HMO's have traditionally focused on preventative health, under the
assumption that early, easy and low fee access to healthcare can prevent
higher costs in the future. You are generally strictly limited in
your providers.
PPO - Preferred Provider Organization -- this type of plan urges
you to receive care from one of their member providers by providing a
higher benefit when you are in network. You often have a co-pay
arrangement, but this varies depending on your plan. PPO's
typically give you more freedom to choose. If you are a member
of a PPO, you should be able to get the PPO price from the doctor,
whether you have met your deductible or not. This is often
overlooked.
Traditional -- This is the healthcare many of us had years ago
before HMO's/PPO's stormed the scene. These plans usually had an
80/20 relationship where you had a deductible amount, and then they paid
80% of the costs, and you paid 20%. You usually had to file claims
after the bills. They are still available and still quite viable.
Supplemental -- These policies are decided to supplement
primary coverage. They can be specific, as in only in the case of
accidents or specific illness or they can be in place to cover the
deductible costs. These policies can be an important component of
a customized health plan.
Deductible -- This is an amount which can be determined by the
insured. It is usually the single highest impact item on the
monthly premium and is one of the most misunderstood. A deductible
is the amount of money the insured has to pay, prior to receiving any
benefits from the insurance company during any one year. The
higher this amount, the less likely the insurance company is to pay out
money, so the lower the premium.
Coinsurance -- this is the benefit most policies pay, once the
deductible has been met, where the insurance company pays a portion of
the medical costs and the insured pays a portion of the costs.
Out of Pocket or Stop Loss -- this is the amount, after
deductible and coinsurance levels, where the insurance pays all the
costs as covered in the policy. This is an important determination
when looking at the real costs of a policy.
Co-pay -- This is a feature of plans where doctor visits
require a flat fee prior to access. This usually only applies to
non-well visits, meaning it has nothing to do with annual physicals and
does not usually cover lab tests or x-rays. This is a high focus
item of health plans, but often can cost far more than the cost of the
benefit when compared annually. This is another high impact item
on the insurance cost.
Hospital Fee -- Many plans have a separate hospital
deductible. This can also apply to emergency room visits.
The intent is to prevent frivolous use of the facilities, and it is
often waived if the patient is admitted.
HSA -- These plans are a combination of health insurance
and tax deferred investment. Basically they are quite simple.
You contribute an annual amount, usually similar to your deductible, to
a savings vehicle. If you require health care, you access this
money, if you don't you save it and it grows with interest,
tax-deferred. The policy has all the other health coverage of
other policies, but also offers a tax advantage way to save for future
health costs. MSA's were available to business owners, but now
HSA's are available to nearly everyone. It is just as easy to set
up an HSA as it is a regular major medical policy. |