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Health Insurance Plans - What's The Difference?
All health plans are not created equal. And there's no rule of thumb for which ones are good and which ones aren't. The best plan for one person may not work at all for another. The best plan for you will depend on just what kind of health care you need, whether you have family members and what their needs are, and a few other personal factors.
Which Health Insurance Plan is Right for You?
Features and options vary widely among types of plans more so than among companies providing the plans. Where things vary among companies is usually cost. Depending on your personal circumstances, some health insurance companies' rates may be less than others. During your job search, it's a good idea to consult any prospective employers on what their health benefits are; since some employers will provide more health insurance coverage then others.
But you don't need to be an expert, or even spend a lot of time, to figure out which plan type is best for your needs. Understanding which type of plan offers the things you want should make a decision pretty easy.
Health Maintenance Organization (HMO)
HMOs are the oldest form of managed care and are typically the least expensive way to receive medical care. HMOs offer a range of benefits, including preventive care, for a set monthly fee. HMO plans generally do not have deductibles. Rather, you make a co-payment for the services performed. For example, doctor visits may cost $20. However, HMO plans require you to get a referral from your Primary Care Physician before the plan will cover treatment by a specialist. Your Primary Care Physician must belong to a specified medical group.
You do, however, choose a primary care physician from a list of participating doctors. If you need to see a specialist, need to be hospitalized, or have lab or X-ray work; your doctor will refer you to a provider or facility. Your doctor must give authorization for those services to be covered by your HMO. You also might have to pay some portion of the cost, called a co-payment, for each office or hospital visit, such as $15 per doctor visit, regardless of what the services cost. Some services such as; emergency room, mental health and chemical dependency services, may also require extra fees.
Preferred Provider Organizations (PPO)
PPO plans allow you to use any physician when medically necessary. However, if you opt to use a Preferred Provider from the list of participating providers, the company will pay for a higher percentage of the costs. For example, a PPO plan may pay for 80% of the medical expenses if you are treated by a Preferred Provider, and only 60% if you are treated by a Non-Preferred Provider. When you use a Non-Preferred Provider, you may also be responsible for any amount billed over customary and reasonable charges.
You will have choices to make about your insurance options within the PPO system when you enroll. Your decisions will apply to you and any dependents you enroll in the plan, and can usually only be changed once a year during "open enrollment" periods. You'll receive a list of participating medical professionals, which you can use to find health care. Or you may continue to see anyone you already use.
You may have to pay a portion of the cost for each office or hospital visit, regardless of how much the visit costs. Your portion is the "co-payment." Also, you may have to pay extra for some services like, the emergency room, mental health and chemical dependency services, for example.
Point-Of-Service
These plans combine characteristics of HMOs and PPOs. You choose a primary care physician who controls all aspects of care, including referrals to specialists. All care received under that physician's guidance, including referrals, is fully covered. Care received by out-of-plan providers is reimbursed, but you have to pay a significant co-payment or deductible. So basically, you decide each time you need medical care whether you want to use your plan as an HMO or a PPO.
Major Medical
Major Medical is the least restrictive option of the three main health insurance plans. Major medical lets you see any licensed health care professional for anything covered by the insurance. You choose a deductible and other option when you enroll, and those apply to you and any dependents you enroll in the plan.
The deductibles you choose apply to each person enrolled in the plan; so if you and a spouse enroll and select a $250 deductible, you each must pay $250 in medical expenses before your plan starts paying further costs each year. But companies typically set a maximum of two or three deductibles per family.
Costs that exceed your deductible are covered by a coinsurance plan, so you and the insurance company share the cost for services covered by the policy. For example, with an 85/15 provision, the insurance company pays 85% and you pay 15%. After you meet your deductibles, coinsurance maximums apply that protect you from skyrocketing bills. You may have to pay extra for some services such as, emergency room, mental health and chemical dependency services, for example.
After deciding on what coverage is right for you, use Anikim.com's online health insurance questionnaire to compare health insurance quotes online.
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