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Typically, you must receive a referral from your physician before visiting a specialist outside the provider network. With rare exceptions, such as when you are away traveling, you are limited to seeking care completely within the network of providers, doctors, hospitals and labs with whom your HMO has negotiated a fee schedule.
Since contracting discounts from a network of providers is one of the primary ways a HMO maintains cost effectiveness, the plan only works when you stay within the network. In addition to your premium, an HMO generally charges a copayment (a way of sharing per-visit costs between the consumer and the plan) of around $10 to $20 for certain services or prescriptions. One of the unique features of an HMO is that they typically deliver care directly to patients. Patients visit an HMO’s medical facility to see the physicians. Most HMOs own their own hospitals and clinics and directly hire physicians who work only for them.
While an HMO is more restrictive than other plans, it can be a convenient and cost-effective solution for an insurance consumer that does not have ties to a doctor or medical facility outside of the HMO’s network. If the organization is well run, doctor visits and health care can be simple, hassle-free and reliable. If the need arises for you to see a specialist, your doctor will handle the research for you; all you will need to do is show up for your scheduled appointment.
— Preferred Provider Plan (PPO)
Health insurance companies contract a network of doctors and hospitals that are “preferred” by the company. These network doctors and hospitals charge a contracted fee for their services, and when you choose to see one of these “preferred providers,” the amount you pay out of pocket is usually quite low. There is typically a small copayment (a fee per visit or service), which may be $15 or $20. It is important to keep in mind that since the insurance companies keep prices lower by contracting specific doctors and hospitals, there is a higher charge for going out of the health-care provider’s network. However, the PPO is a more flexible arrangement than many other plans because the plan will pay some of the costs if you choose to visit a doctor, specialist or clinic outside the network.
— Point of Service (POS) Plan
POS plans have similarities to both PPO and HMO plans. As with PPO plans, you are directed toward a network of contracted doctors, hospitals and clinics for your health care, but you can pay a larger out-of-pocket fee to visit an out-of-network provider. In line with the managed-care policies of an HMO, your health care is administered according to a health-care professional. With a POS plan, your primary doctor oversees your medical care and refers you to contracted specialists when the need arises. Similar to the philosophy of an HMO, POS plans promote health and wellness through prevention and education in addition to treatment.
The upside to a POS plan is the freedom to go out on your own and choose your own providers, even specialists, outside the network. You are never limited to medical providers that your primary-care physician refers. However, be aware that the dollar amount the plan will pay decreases when you go outside the network.
You will pay approximately $600 a year for the privilege of being allowed to self-refer to out-of-plan practitioners, and your out-of-pocket contribution will be greater. It is wise to consider if it is worth it to you, as a consumer, to pay a higher monthly payment for the freedom to access specialists, physicians and clinics of your choice. If you are relatively healthy and do not have a special relationship to a specific physician, you might consider a managed-care program that will charge you less to exercise less freedom in choosing a health-care provider. If the freedom to self-refer to any health-care practitioner or hospital you want is important to you, a POS plan may be your ideal fit.
— Health Savings Account (HSA)
As of January 1, 2004, health-care consumers have had a new way to help manage their own health care. Health Savings Accounts (HSAs) provide consumers with added insurance coverage and control. Flexibility is the key component of an HSA. Anyone with a high-deductible health plan can set up an HSA to save money on medical care now as well as save for future medical expenses. You may use HSA funds to pay for expenses that must be met before your deductible, to pay for services not covered by your health plan (such as alternative therapies or out-of-network providers) or insurance coverage during periods of unemployment.
Even if you purchase your insurance plan or your HSA through your employer, you still own your account. You make the decisions on how much to contribute to your account and which medical expenses you will use the funds to pay. When you change jobs or move, the account remains intact. Any unspent balances remain in your account earning interest until you spend them on medical care.
An HSA can be a comforting safety net if you have a high-deductible plan (your plan won’t begin paying out until your financial responsibility is met). In the event that you lose a job, must seek uncovered medical services or just want to exercise your right to seek a specialist not contracted with your insurance plan, the funds in an HSA one day may be your saving grace. If you are a consumer who desires security and values freedom, an HSA is an option you should research.
— Self-Directed Health Plan (SDHP)
These also can be called consumer-directed health plans, and they are a way to organize, purchase and finance health-care services. These plans succeed in providing consumers with a method by which they can design and implement their own health plan that can be customized to their specific needs, health-care philosophies and circumstances.
Since contracting discounts from a network of providers is one of the primary ways a HMO maintains cost effectiveness, the plan only works when you stay within the network. In addition to your premium, an HMO generally charges a copayment (a way of sharing per-visit costs between the consumer and the plan) of around $10 to $20 for certain services or prescriptions. One of the unique features of an HMO is that they typically deliver care directly to patients. Patients visit an HMO’s medical facility to see the physicians. Most HMOs own their own hospitals and clinics and directly hire physicians who work only for them.
While an HMO is more restrictive than other plans, it can be a convenient and cost-effective solution for an insurance consumer that does not have ties to a doctor or medical facility outside of the HMO’s network. If the organization is well run, doctor visits and health care can be simple, hassle-free and reliable. If the need arises for you to see a specialist, your doctor will handle the research for you; all you will need to do is show up for your scheduled appointment.
— Preferred Provider Plan (PPO)
Health insurance companies contract a network of doctors and hospitals that are “preferred” by the company. These network doctors and hospitals charge a contracted fee for their services, and when you choose to see one of these “preferred providers,” the amount you pay out of pocket is usually quite low. There is typically a small copayment (a fee per visit or service), which may be $15 or $20. It is important to keep in mind that since the insurance companies keep prices lower by contracting specific doctors and hospitals, there is a higher charge for going out of the health-care provider’s network. However, the PPO is a more flexible arrangement than many other plans because the plan will pay some of the costs if you choose to visit a doctor, specialist or clinic outside the network.
— Point of Service (POS) Plan
POS plans have similarities to both PPO and HMO plans. As with PPO plans, you are directed toward a network of contracted doctors, hospitals and clinics for your health care, but you can pay a larger out-of-pocket fee to visit an out-of-network provider. In line with the managed-care policies of an HMO, your health care is administered according to a health-care professional. With a POS plan, your primary doctor oversees your medical care and refers you to contracted specialists when the need arises. Similar to the philosophy of an HMO, POS plans promote health and wellness through prevention and education in addition to treatment.
The upside to a POS plan is the freedom to go out on your own and choose your own providers, even specialists, outside the network. You are never limited to medical providers that your primary-care physician refers. However, be aware that the dollar amount the plan will pay decreases when you go outside the network.
You will pay approximately $600 a year for the privilege of being allowed to self-refer to out-of-plan practitioners, and your out-of-pocket contribution will be greater. It is wise to consider if it is worth it to you, as a consumer, to pay a higher monthly payment for the freedom to access specialists, physicians and clinics of your choice. If you are relatively healthy and do not have a special relationship to a specific physician, you might consider a managed-care program that will charge you less to exercise less freedom in choosing a health-care provider. If the freedom to self-refer to any health-care practitioner or hospital you want is important to you, a POS plan may be your ideal fit.
— Health Savings Account (HSA)
As of January 1, 2004, health-care consumers have had a new way to help manage their own health care. Health Savings Accounts (HSAs) provide consumers with added insurance coverage and control. Flexibility is the key component of an HSA. Anyone with a high-deductible health plan can set up an HSA to save money on medical care now as well as save for future medical expenses. You may use HSA funds to pay for expenses that must be met before your deductible, to pay for services not covered by your health plan (such as alternative therapies or out-of-network providers) or insurance coverage during periods of unemployment.
Even if you purchase your insurance plan or your HSA through your employer, you still own your account. You make the decisions on how much to contribute to your account and which medical expenses you will use the funds to pay. When you change jobs or move, the account remains intact. Any unspent balances remain in your account earning interest until you spend them on medical care.
An HSA can be a comforting safety net if you have a high-deductible plan (your plan won’t begin paying out until your financial responsibility is met). In the event that you lose a job, must seek uncovered medical services or just want to exercise your right to seek a specialist not contracted with your insurance plan, the funds in an HSA one day may be your saving grace. If you are a consumer who desires security and values freedom, an HSA is an option you should research.
— Self-Directed Health Plan (SDHP)
These also can be called consumer-directed health plans, and they are a way to organize, purchase and finance health-care services. These plans succeed in providing consumers with a method by which they can design and implement their own health plan that can be customized to their specific needs, health-care philosophies and circumstances.
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