Continued from page 1
In addition to idemnity plans, there are basically three types of managed care plans: PPOs, HMOs, and POS plans. Preferred Provider Organizations (PPOs) are closest to an idemnity plan. A PPO has arrangements with doctors, hospitals and other care providers who have agreed to accept lower fees from
insurer for their services. As a result, your cost sharing should be lower than if you go outside network. If you go to a doctor within PPO network, you will pay a copayment (a set amount you pay for certain services--say $10 for a doctor of $5 for a prescription). Your coinsurance will be based on lower charges for PPO members.
If you choose to go to a doctor outside network, you will have to meet deductible and pay coinsurance based on higher charges. In addition, you may have to pay difference between what provider charges and what plan will pay.
HMOs are oldest form of managed care plan. HMOs offer members a range of health benefits, including preventive care, for a set monthly fee. There are many kinds of HMOs. If doctors are employees of health plan and you visit them at central medical offices or clinics, it is a staff or group HMO. Other HMOs contract with physician groups or individual doctors who have private offices. These are called individual practice associations (IPAs) or networks.
HMOs will give you a list of doctors from which you must choose a primary care doctor. The doctor coordinates your care, which means that generally you must contact him or her to be referred to a specialist. With some HMOs, you will pay nothing when you visit doctors. With other HMOs there may be a copayment, like $5 or $10, for various services.
If you belong to an HMO, plan only covers cost of charges for doctors in that HMO. If you go outside HMO, you will pay entire bill.
Many HMOs offer an indemnity-type option known as a Point-of-Service Plan or POS. The primary care doctors in a POS plan usually make referrals to other providers in plan. However, in a POS plan, members can refer themselves outside plan and still get some coverage.
If doctor makes a referral out of network, plan pays all or most of bill. If you refer yourself to a provider outside network and service is covered by plan, you will have to pay coinsurance.
Whatever your choice of plans, medical insurance is rapidly becoming an absolute essential commodity. With cost of a simple doctor's visit approaching $65 and with major procedures now costing thousands upon thousands of dollars, you can not afford to be without health insurance for you and your family.
Larry Denton is a retired history teacher having taught 33 years at Hobson High in Hobson, Montana. He is currently V.P. of Elfin Enterprises, Inc., an Internet business providing valuable information on a variety of timely topics. For a waiting room full of tips, resources and advice about health insurance, visit http://www.HealthInsuranceGate.com
