Health & Dental Insurance
What is the difference between PPO and HMO coverage?
PPO: Preferred Provider Organization is a network of physicians and hospitals that have agreed, by contract, to discount their rates to members. The networks are typically very large and the members are free to seek care from ANY physician or provider within the network. This includes specialists without a referral! Members may also access non-contracted providers, but at a higher out-of-pocket cost. This is called out of network benefits. PPO plans usually come with deductibles, co-pays, prescription benefits and a co-insurance. There is always an "out of pocket" maximum amount associated with each policy. Once a member reaches their "out of pocket" maximum, they are at 100% level of coverage for all covered benefits for the remainder of the calendar year.
HMO: Health Maintenance Organization provides very rich benefits - very low out-of-pocket costs. There is typically no coverage for care from doctors or hospitals outside of the HMO plan. HMO plans usually offer comprehensive benefits, but the premiums can be very high. Each member must select a PCP (Primary Care Physician) that you choose from a network. This Primary Care Physician oversees all of your care. Unless you have a direct access feature in your plan - your Primary Care Physician will coordinate referrals to specialists whenever necessary.
INDIVIDUAL HEALTH INSURANCE - coverage for those without an employer-sponsored group plan
The vast majority of U.S. citizens who have health coverage (about 57%) get this coverage through their employer's group plan. Another 29% get coverage through a government plan (Medicaid, Medicare or the Military). If you are self-employed, or if your employer does not offer a group health plan, then you are likely to turn to the private market to purchase an individual health insurance policy. Getting individual coverage can be more difficult than qualifying for a group health plan offered by an employer. This is because individual applications are underwritten. This means the insurance company will closely scrutinize your medical history - often going back as much as10 years.
IT PAYS TO BE TRUTHFUL: When you apply for coverage, be sure to disclose any medical problems you've had, no matter how insignificant you perceive the problems to be! If you don't your policy may be subject to rescission. This is when an insurance company cancels your policy due to undisclosed conditions or inconsistencies.
BUY ONLY WHAT YOU NEED - BUT DO BUY! It sounds dire, but it is essential that you have health insurance for you and your family! More than 60% of all bankruptcies in the United States are the result of medical bills. Sadly, if you're self-employed, you could be one major illness away from bankruptcy or losing your business.
WHAT CAN YOU DO? Learn how to manage your risk. Decide how much debt you can manage should a serious illness or accident occur. Then consider opting for a high-deductible type of policy! You'll pay for all of your normal medical bills out of pocket and rely on your insurance policy only in the event of a truly catastrophic illness or accident.
Most of the information on this page was obtained from government agency websites and publications, including the Health Insurance Resource Center, Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (DHHS), National Institutes of Health (NIH), Social Security Administration (SSA) and HealthReform.gov. All content is provided for informational purposes only and is subject to change without notice. Although we believe that the source of this information is reliable, we do not warrant or guarantee its accuracy, completeness or timeliness.
TheHealthInsuranceLINK.com contains information about and access to insurance plans for people who are eligible for Medicare and seniors in general and others seeking health insurance coverage. It is operated by Lunzer & Associates Insurance Services LLC., a licensed health insurance agency. Lunzer & Associates and this website are not associated with or endorsed by Medicare, the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (DHHS) or any other government agency.