HMO Plans offer prepaid comprehensive health coverage for both hospital & physician services. Members are required to select a primary care physician (PCP) that is part of the contracted provider network.
- Routine visits are typically covered with a nominal co-payment.
- Usually there are no claim forms or deductibles to satisfy – depending on the plan.
- Emergency care is covered anywhere in the world.
- Routine gynecological care is typically available without a referral. Coverage is typically provided for pregnancy, including prenatal, delivery, and post-partum care.
- HMO’s have a large focus on preventative care and keeping members healthy.
A PPO plan gives members the option of receiving medical care from participating providers or non-participating providers or a combination of both. When receiving care from a participating provider, there is generally a co-payment for an office visit. For other than routine office visits, employees could also pay a deductible, coinsurance, or both. When visiting a non-participating provider, the appropriate coinsurance and deductible amounts will apply. It is definitely more advantageous for an employee to go to an In-Network or participating provider.
- PPO providers are paid on a fee-for-service basis as their services are used. A scheduled co-payment is paid by the employee, usually ranging from $10 to $25.
- Insured’s that use a network provider pay lower deductibles or co-payments or receive broader types of covered care.
- Usually employees do not need referrals to see specialists.
- Usually no claims paperwork if insured uses a network provider.
EPO’s are similar to PPO’s except you must go to participating providers for health care services.
A Point of Service Plan is a hybrid arrangement that combines aspects of a traditional HMO and a PPO. With a POS plan, participants in the plan elect, at the time medical treatment is needed, whether to receive treatment within the plan’s tightly managed network, usually an HMO, or go outside the network. Usually the term POS implies a higher degree of managed care than is found in most PPO’s.
- Insured’s have ability to control out-of-pocket expenses by seeing participating primary care physicians but freedom to go elsewhere is desired.
- A referral to a network specialist is needed from primary physician, but a referral is not needed for non-network services.
- Small co-payments for network services; deductibles and percentage participation for non-network services.
- Preventative care usually covered.
Employers with a large number of employees and a relatively healthy group may want to consider self-funding. The business acts like its own insurance company and assumes its own risks. The exposure of catastrophic losses is covered by stop-loss insurance. Businesses must be in a position to be able to administer the plans themselves, but can design the plan to provide benefits on an indemnity basis or as an HMO or PPO.
Our agency has access to carriers that offer Stop-Loss Insurance.
Indemnity insurance is the “standard” type of health insurance someone can purchase to cover comprehensive major medical benefits. The carrier reviews the claim and then reimburses the insured for the appropriate amount.
Indemnity Plan Features:
- Access to a physician of your choice.
- A deductible must be met before any coverage applies.
- Insured pays a coinsurance payment for covered services.
- Claim filing is the responsibility of the insured.