Frequently Asked Health Insurance Questions

Choosing between health plans is not as easy as it once was. Although there is no one "best" plan, there are some plans that will be better than others for you and your family's health needs. Plans differ in how much you have to pay and how easy it is to get the services you need. Although no plan will pay for all the costs associated with your medical care, some plans will cover more than others.

With any health plan you will pay a basic premium, usually monthly, to buy the health insurance coverage. In addition, there are often other payments you must make. These payments will vary by plan but essentially are deductibles and copayments.

Here's a list of key questions to consider in selecting the plan that best meets your needs:

• How much will it cost me on a monthly basis?
• Are there deductibles I must pay before the insurance begins to help cover my costs? After I have met the deductible, what part of my costs are paid by the plan?
• What doctors, hospitals, and other medical providers are part of the plan? Are there enough of the kinds of doctors I want to see?
• Where will I go for care? Are these places near where I work or live?
• If I use doctors outside a plan's network, how much more will I pay to get care?
• Are there any limits to how much I must pay in case of major illness? What about limits and deductibles for certain types of care such as surgery or maternity?

The above content was used with permission from the Agency for Health Care Policy and Research and Health Insurance Association of America.

A PPO is a Preferred Provider Organization. As a member of a PPO, you can use the doctors and hospitals within the PPO network or go outside of the network for care. You do not need a referral to see a specialist.

• If you obtain care from a medical provider outside of the PPO network, you will pay more for the service. For example, a PPO might pay 90 percent of the cost for a visit with an in-network doctor but only 70 percent of the cost for a visit to a non-network doctor.
• You will typically pay a copayment for each visit/service. These copayments are typically higher than an HMO copayment but not always.
• You will usually be responsible for paying an annual deductible.

If you join a PPO, you should find you have more flexibility than with an HMO, but your total out of pocket costs are likely to be somewhat higher.

An HMO is a Health Maintenance Organization. As a member of an HMO, you select a primary care physician from a list of doctors in that HMO's network. Your primary care physician will be the first medical provider you call or see for a medical condition. He or she will make any needed referrals to a medical specialist. Typically, these specialists will be part of the HMO network.

• If you obtain care without your primary care physician's referral or obtain care from a non-network member, you may be responsible for paying the entire bill. (with exceptions for emergency care)
• With some HMOs, you pay nothing when you visit in-network doctors. With other HMOs there may be a small copayment for the visit or service.
• With most HMOs you will not be responsible for paying a deductible.

If you join an HMO, you should find that you have few out-of-pocket expenses for medical care -- as long as you use doctors or hospitals that are part of the HMO.

POS is a Point-of-Service Plan A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs). You can decide whether to go to a network provider and pay a flat dollar or to an out-of-network provider and pay a deductible and/or a coinsurance charge.

An indemnity plan is commonly known as a fee for service or traditional plan. If you select an Indemnity plan you have the freedom to visit any medical provider. You do not need referrals or authorizations; however, some plans may require you to precertify for certain procedures.Most indemnity plans require you to pay a deductible. After you have paid your deductible, indemnity policies typically pay a percentage of "usual and customary" charges for covered services; often the insurance company pays 80% and you pay 20%. Most plans have an annual out of pocket maximum and once you've reached this they will pay 100% of all "usual and customary" charges for covered services.

Many health insurance companies have moved away from indemnity plans and are instead offering managed care plans such as HMOs and PPOs. You may have few or no indemnity plan choices in your area.

A provider is a hospital, healthcare facility, physician or other medical professional that provides healthcare services.

A physician or other medical professional who serves as a group member's first contact with a plan's healthcare system. Also known as a primary care provider, personal care physician, or personal care provider.