Commercial Lines Insurance

    Health Insurance

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There are many forms of health insurance but the three basic formats are the Traditional Indemnity Plan, the HMO (Health Maintenance Organization) and the PPO (Preferred Provider Organization).

The traditional indemnity plan typically has an up-front deductible that must be met before the insurance begins to pay. Once the deductible has been satisfied, most indemnity plans then pay 80% while the insured person pays 20% of the bill until a pre-set out-of-pocket limit is reached. Once this out-of-pocket limit is reached the plan pays 100% of covered medical charges.

Traditional indemnity plans do not require the insured person to select a primary care physician, get referrals or use any specific doctors, labs or hospitals although some procedures may have a reduced out-of-pocket cost if performed in a designated network or facility.

HMO, (Health Maintenance Organizations) generally have a small co-pay for doctor visits rather than an up-front deductible. Co-pays can range from $5 per visit to $30 per visit for primary care and $40 or more for specialists, depending upon the plan chosen by the employer.As an HMO subscriber, you must select a participating Primary Care Physician to manage your care and who will always be your first contact when you seek medical treatment.

HMO plans vary as to referral requirements but generally speaking you must get a referral from your Primary Care Physician before seeking care or treatment from any other specialist or facility. Some HMO plans include an "Open Access" provision which reduces or eliminates the need to get referrals as long as the subscriber sees physicians in the HMO network. Additionally, HMO plans can be purchased with an out-of-network option so that subscribers can go to physicians and facilities that are not in the HMO network. Using the out-of-network option requires greater out-of-pocket expense for the subscriber and may also subject the subscriber to additional balance billing if charges for services exceed that which is customary for the HMO to pay. Always be sure you understand your out-of-network benefits and communicate with the physician or facility about charges BEFORE getting care.

PPO (Preferred Provider Organization) plans have established a network of hospitals, facilities and physicians that must be used by their subscribers in order to receive benefits. The PPO plan does not require that a subscriber select a primary care physician or get referrals. The subscriber must simply use physicians, hospitals and facilities that are in the network. Many PPO plans also have an out-of-network option but again, out-of-pocket expenses for the subscriber will be greater and the risk of additional balance billing is a factor to consider. Know your benefits and communicate with providers BEFORE receiving services.

Emergency care when traveling in the U.S.A. is normally treated as in-network however your care will be transitioned back to the network and your primary care physician as soon as medically practical. It is important to check with your HMO, PPO or Indemnity plan insurer before traveling outside the United States to ensure that coverage will be available should you require emergency treatment. Regardless of your HMO, PPO or indemnity plan's stand on emergency coverage outside the United States, it may be a good idea to purchase a travel medical insurance policy that includes air ambulance coverage to return you to
the United States in the event of an accident or sudden illness.