Indemnity...
With an indemnity plan you can use any
medical provider (such as a doctor and
hospital). You, or they, send the bill
to the insurance company, which pays
part of the cost.
Once you meet the deductible, most
indemnity plans pay a percentage of what
they consider the usual and customary
charge for covered services. The insurer
generally pays 80 percent of the usual
and customary costs and you pay the
other 20 percent, which is known as
coinsurance. If the provider charges
more than the usual and customary rates,
you will have to pay both the
coinsurance and the excess charges.
Preferred Provider Organization (PPO)...
A PPO negotiates discounts with doctors,
hospitals, and other providers of care
who will accept lower fees from the
insurer for their services. As a result,
the premiums are lower because some of
the provider payments will be
discounted.
If you go to a doctor within the PPO
network, you will pay a copayment. Your
coinsurance will be based on the
negotiated discounted charges for PPO
members. For example, the insurer may
reimburse you for 90 percent of the cost
if you go to a provider within the
network. If you choose to go a provider
out of the network, the insurer might
only reimburse you for 60 percent of the
cost.
Point-of-Service (POS)...
Many HMOs offer plan members the option
to self direct care, rather than get
referrals from primary care physicians.
When medical care is needed, the
individual plan member essentially has
up to two or three choices, depending on
the particular health plan. The plan
member can choose to go through his or
her primary care physician, in which
case services will be covered under HMO
guidelines (i.e., usually a copayment
will be required). Alternatively, the
plan member can access care through a
PPO provider and the services will be
covered under in-network PPO rules
(i.e., usually a copayment and
coinsurance will be required). Lastly,
if the plan member chooses to obtain
services from a provider outside of the
HMO and PPO networks, the services will
be reimbursed according to
out-of-network rules (i.e., usually a
copayment and higher coinsurance charge
will be required).
Health Maintenance Organization (HMO)...
In an HMO, instead of paying for each
service that you receive separately,
your coverage is paid in advance. This
is called prepaid care. For a set
monthly fee, HMOs offer members a range
of health benefits, including preventive
care, but typically care must be
authorized by your primary care
physician.
HMOs will give you a list of doctors
from which to choose a primary care
physician. This doctor coordinates your
care, which means that generally you
must contact him or her to be referred
to any specialist. Typically, with most
HMOs there is a copayment for office
visits, hospitalizations, and other
health services.
|