Understanding Your Health Care Plan
Don't know your PPO from your POS? Health care plan names and features can be confusing. Plans will differ in how much you have to pay and how easy it is to access the services you need. Below is a general description of the most popular types of health care plans around today.
If you are able to choose among health care plans, look for one that will help take care of your long-term needs because of your seizure disorder. Still, even if your health care choices are limited, remember one point: Health care is simply too important to live without.
With an indemnity plan (sometimes called fee-for-service), you can use any medical provider (such as a doctor or hospital). You, or the medical provider, send the bill to the insurance company, which pays part of the bill (if the service is covered by the plan), and you pay the other part of the bill.
Most indemnity plans also make you pay a "deductible." This means you pay a certain amount, such as $500, before the insurance company begins to pay. After you meet the deductible, most indemnity plans pay a percentage of the medical service provided. Frequently, the insurance company pays around 80 percent of the bill and you pay 20 percent.
Indemnity plans pay for medical services, medical tests, and prescriptions; however, these plans usually don't pay for preventive care, such as annual exams.
Most health care plans today fall under the "managed care" umbrella. In general, the doctors or hospitals you visit are somewhat restricted, but more preventive services are covered. The following describes some types of managed care plans; however, these descriptions change as health care plans compete for business.
Preferred Provider Organization (PPO). With a PPO, you choose from a list of doctors or hospitals within a network. These health care providers have agreed to limit fees on the services they provide. If you visit health care providers within the network, your costs will be lower than if you seek care outside of the network. (Often you pay the full cost of health care if you visit doctors or hospitals outside the network.) You can visit any of the doctors or hospitals within the network without a referral from a primary doctor.
When you visit a PPO doctor or hospital, you usually must make a "co-payment," which is a set amount you pay for certain services. For example, when you visit the doctor, you may pay a $15 or $20 co-payment. The remainder of the bill is sent to the insurance company for payment. However, under some plans, the individual must pay the entire cost of the medical visit and then must file a claim with the insurance company for reimbursement. In addition to a co-payment, some PPO plans also make you pay a deductible (described above). The deductible is common if you visit doctors and hospitals outside the PPO network.
Health Maintenance Organization (HMO). HMOs offer members a range of health benefits, including preventive care, for a set monthly fee. There are many kinds of HMOs. Some HMOs operate central medical facilities or clinics. Other HMOs feature a group of doctors who maintain private offices.
With an HMO, you select a primary care physician. The primary care physician coordinates your health care and you usually must contact him or her to be referred to a specialist.
When you visit an HMO doctor or hospital, you usually make a co-payment; however, you won't face a deductible. If you seek medical care from doctors or hospitals outside the HMO, you must pay the full cost of that care.
Point-of-Service (POS) Plan. POS plans blend many of the features of an indemnity plan, PPO plan and HMO. With a POS plan, you will pay the lowest cost if you visit doctors or hospitals within the network. You select a primary care physician, but can seek care from specialists without a referral. However, if you go to specialists--inside or outside the network--without a referral from your primary doctor, your costs will be higher.
You will pay a co-payment with a POS plan. The co-payment amount typically is less expensive if you visit doctors within the network. If you seek care outside the network, the plan will pay part of the cost, but your share will be larger. Also, if you go to doctors and hospitals outside of the network, you likely will face a deductible.