If you are searching for an individual health plan, or need to choose between company group benefits, you should understand your choices. The best choice for you will depend upon many things, including your health needs, budget, and the available health insurance types in your location. We tried to simplify one of the most common questions that consumers have, and that is the difference between an HMO and a PPO health plan.
HMO (Health Maintenance Organization) – This type of coverage includes a network of medical providers. Those providers include doctors, hospitals, pharmacies, and other service providers. The providers are included in the network because they agree to the networks terms, which include cost guidelines. In return, a medical provider can be assured of a steady stream of patients from being included on the published list.
An insured person must almost always seek a network provider in order to be covered. In return, they usually get the most coverage with the lowest copays and coinsurance compared to other types of health care plans. Managed care plans like this are usually very simple for the consumer to use, and the medical provider will handle most of the paperwork and billing.
In the case of an emergency, the strict network restriction will usually be waived, and that exception should be spelled out in the policy. If a covered person needs some service that is not included in the network, they may be covered if they can get pre-approval from the network. In any non-emergency situation, the insured person should always get a non-network medical service pre-approved by the insurer, and they should have that approval in writing.
PPO (Preferred Provider Organization) Health Plans – LIke HMO plans, PPO plans use a network of medical providers. If the insured person uses that network they will get the highest levels of coverage, and have the least out of pocket expenses. They will also be allowed to use non-network providers in an emergency situation, and may be able to seek exceptions in other special situations. Of course, these non-emergency exceptions should always be pre-approved!
But a PPO is not as restrictive because they also cover non-network medical services. They just cover them at a lower rate. For instance, a visit to a network doctor may only require a $20 copay. But a visit to a non-network doctor may require a $50 copay. In network hospital bills may be covered at 80% after a $1,000 deductible, but non-network hospitals may only be covered at 50%. These are just examples, and are not meant to represent the actual terms of any health insurance company.
Which Health Plan is Best?
No one plan works out best for everybody. Many people enjoy the simplicity of HMO plans, especially if they live in an area with a large and active network. Others want the freedom to seek medical services outside the network, and those people would probably be happier with a PPO. Of course, your choice will also depend upon what plans are available in your local area, and upon your budget and medical needs.
By: Marilyn Katz
Posts Tagged ‘Individual Health’
Compare Health Insurance Plans – PPO Or HMO Health Insurance
November 12th, 2009Health Insurance For People Over 50
October 10th, 2009
For anyone between 50 and 65 years who will be looking for some health cover or is already looking, you could be in need of a lot of help. This age is crucial in that many of the body’s systems are just about ready to start failing plunging you into serious health challenges. Using statistics (a tool used extensively to create the product structures) insurance companies know that the expenditure on health for the 20 to 45 year-old group will be a lot less than for the 50 to 65 year-old group. Therefore, the premiums for older persons are higher.
Do not despair, as we are smart we will be sure to find a way. Let us look at some options available.
For those who are still working and may be looking at starting a business or going to retire, there are a few areas worthy of your investigating. Does the company you work for allow you to buy insurance through their plan? For early retirement, if the company allows, they may be able to subsidize a portion of the premiums. If there is no subsidy, you may still be entitled to group rates which are less than for individuals. If you spouse will remain in employment seriously look at joining their plan if this is possible.
Another option is COBRA or Consolidate Omnibus Budget Reconciliation ACT, for those still in employment that gives health insurance cover. Former employees and their families can continue the cover for up to a year and a half. COBRA is also guaranteed. You can not be turned down even for chronic illnesses. The downside is the cost. During your employment the employer normally meets 70% of the premium. Own your own you will cover the full premium and administration costs on top. A 1997 survey showed that on average a retired employee would pay $1,008 for family cover and $373 for the individual health cover.
Even if you are not in employment, there are some options open for you. For those with pre-existing conditions like high blood pressure or diabetes who fail to get insurance, coverage is still available through the states’ high-risk program especially set up to help this group of people. Like COBRA, the premiums are quite high.
You should also check professional organizations that you could join or already a member of or are affiliated to see if the membership offers health insurance cover. As this is a group cover, your premiums will be low.
Lastly, the health insurance scheme for individuals. There are now very good offerings in this area as providers believe the 50-65 age group has potential for growth. These individuals also have a fair income and are in good health. Companies believe that even when the oldies become eligible for Medicare, they will still opt for supplemental cover. Some of these options have monthly premiums as low as $200 for individuals in fair health, but carry high deductibles. Some advisors recommend combining opening health savings accounts (HSA) when taking out a cover with high deductibles. HSA contributions are not taxed, nor are any withdrawals made towards qualified medical expenses and the balance at year end can be rolled over to the next year.
By: Jack Adams
