Private Health Insurance Plans

Health Maintenance Organizations (HMO) Plan or Managed Care

An HMO plan generally provides “in-network” coverage by requiring members to receive services from a Primary Care Physician, or primary doctor. The primary doctor is part of a networked group that also includes hospitals, urgent care facilities, and specialist doctors. If you need more care than your doctor can provide alone, he/she would refer you to a specialist doctor or hospital within the group. These plans do not cover unnecessary costs, but usually have a lower premium rate. You may be required to pay a small co-payment at each doctor visit and for each prescription. Emergency room visits are usually covered, but the insurance company can deny paying the bill if they decide that the visit was not a real emergency. There is a higher co-payment due when you check-in at a hospital and do not get admitted overnight. If you are admitted overnight, services and costs are usually paid in full by the insurance company. HMO plans are regulated by State departments.

Preferred Provider Organization (PPO) Plan

PPO plans have similar coverage to HMO plans, in that, the plan generally covers normal and preventative medical costs and services. PPO plans have more flexibility than HMO plans because it allows a member to see any doctor within their networked group without a referral from their Primary Care Physician, or primary doctor . If you see a doctor outside the networked group, you would be required to pay a higher copayment. A PPO plan best accommodates people who prefer to choose their own doctors without the limitations of a networked group.

Point of Service (POS) Plan

A POS plan tends to be a mix of both the HMO and PPO type plans. The coverage is similar to the HMO plan, which requires a Primary Care Physician to manage your health. The flexibility of the plan compares to the PPO plan, in that, the member is not required to see doctors limited to the networked group. Your primary doctor should still authorize any referrals in or out of the networked group. Without a referral, the insurance company may decide not to pay for the services. Further, if you see a doctor outside the group you may be restricted from services and coverages; such as prescription drugs, organ transplants, infertility treatments, and mental health services. There are many levels of this type of plan to expand its covered cost of services.

Traditional Insurance Plan / Major Medical Plan

A Traditional Insurance Plan and Major Medical Plan are generally the same plan. It is the most flexible type of plan, which also makes it the most expensive type of plan. A member can choose to see any doctor without a referral from a Primary Care Physician. The plan will pay 80% of a medical bill after an annual deductible is paid in full. The member would still be responsible for paying 20% of the medical bill, even after the deductible was paid. There is usually a maximum annual amount you would pay for “out of pocket” medical expenses. There is also a maximum amount the plan would pay for medical expenses in your lifetime. Traditional Insurance Plans are regulated by State departments.