Health Insurance - HMOs, PPOs &
becomes more complicated and confusing every day. With new terms like managed
care, fee-for-service, premium, co-payment, the industry has developed a
language of its own. When dealing with a health condition like hepatitis, you
must understand the health insurance world.
All health care policies are
not created equal. To make a smart choice about which plan is best, you must
first understand the differences. Health insurance plans can be broken into two
basic categories, the traditional fee-for-service plan and the managed-care
plan. While the fee-for-service or indemnity options usually offer full freedom
of choice of service provider, these plans are typically more expensive.
Managed care options limit the choice of service provider in different ways but
are generally more economical.
With the least freedom and cost, the
Health Maintenance Organization (HMO) normally restricts you to a primary care
physician who coordinates your care and must refer you to a specialist. Two
other managed care options give more choice with more expense than an
The Preferred Provider Organization (PPO) gives patients the choice
of staying within the network or seeking care outside the group. If you stay
within the network, 90-100% of the cost is normally covered while if you go
outside the network you submit the claims, similar to an indemnity policy, and
typically get 70% of the cost covered.
Less expensive than PPOs,
Point-of- Service plans (POS) still provide more freedom than HMOs. For basic
care, you can stay within the network, but if you choose to see a specialist
outside the network you simply pay a percentage of his charges.
choosing a health care plan, consider the access it gives you to specialists.
Typically in HMOs, a patient's care is managed by a primary care physician, the
gatekeeper, provides the majority of care and controls access to specialists,
tests, and procedures. Their goal is to keep costs down which may mean limiting
specialists and certain tests. Some plans may not even have hepatologists or
gastroenterologists familiar with hepatitis within their network so it is
essential to select a plan that gives you the experts you need.
care plans may limit accessability to emergency rooms. Know what type of
restrictions exist before you can go to an emergency room, Do you need approval
from the gatekeeper? And, what if you are out of town? Will the managed care
plan cover for you to see someone out of the network? Do you need approval
first? Their goal is to keep costs down which may mean limiting specialists and
Also, consider the access to treatments, medications, and
tests it gives you, particularly experimental treatments. There are not a lot
of medications to treat hepatitis and it is a long process before medications
receive "official" approval. Will your plan allow you to access the
experimental treatments? Check to see if your plan covers medications and ask
to see the list of covered drugs. Find out if medications like interferon are
covered and for what conditions. In addition, a limit may exist on the lifetime
amount the plan will pay towards drugs.
If you decide to buy indemnity
insurance, stick with a major medical policy which covers both hospital stays
and physician services in and out of the hospital. There are cheaper plans
which offer a fixed rate per day in the hospital or dread-disease policies
which pay only if you contract a specific disease like cancer but these
policies give you very limited coverage.
Premium costs vary depending on
the type of plan, location, benefits offered, deductible, and age and sex of
person. Generally, the fee for service plan is the most expensive followed in
decreasing order by PPOs, POS plans, and HMOs.
Your true cost cannot
just be judged by the premium alone. There is also the amount that you are
expected to pay, the out-of-pocket-costs. These charges include the deductible,
the annual dollar amount you must spend on health care before the insurance
company picks up the cost. Normally, the higher the deductible the lower the
premium is. The portion of the bill you are expected to pay after your premium
is met is known as the co-payment. With managed care plans this is usually a
nominal fee. In indemnity plans, the co-payment is usually 20% of the fees.
However, the insurance company pays 80% of what they feel is the reasonable and
customary charge for a service even if your doctor charges a larger amount,
leaving you to pay the difference.
Many insurance companies specify a
lifetime cap or maximum dollar amount they will spend for each insured person.
Most set a cap at a $1 million which many experts argue is too low for people
with chronic conditions. Others may set a cap on a condition or even a yearly
Patients need to know how these important details affect their
health care policies. You ought to know how medical care is determined, how "
medically necessary" treatment is determined. If necessary, patients should
know how to appeal these decisions. You also need to know what provider
restrictions exist and how they may effect treatment decisions. Does the doctor
charge a discounted rate based on volume of patients or does he receive a
certain amount per patient per month or year, known as a capitation. If the
patient's care exceeds this amount the doctor must cover the expense. This may
cause a doctor to limit care.www.primarymedicalcare.comPrimary Medical Care Website Medical Disclaimer Information
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