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Health Insurance Guide

Health has always been uncertain. We can try our best to keep fit, but after a certain age the expenses on health do increase. Its better to keep ourselves insured under a Medical Plan to make sure that our medical expenses are taken care of.

If we talk about Individual Health Insurance Plans in US, they are designed to help an individual and their families access care and cover the medical cost of receiving medical services from any physician, hospital or other provider.

There are different types of Medical Plans:

  • Indemnity
  • Health Maintenance Organization
  • Preferred Provider Organization
  • Point of Service Plan
  • Exclusive Provider Organization
  • Consumer-Driven

Health Insurance Portability and Accountability Act (HIPAA) Privacy – Protected Health Information.

Under HIPAA Privacy, unauthorized individuals cannot ask or inquire about any clinical or personal health information when counseling participants about their Medical Plans.

Indemnity Plans – These plans are sometimes called “Free-for-Service” Plans, where:

  • An individual pays the medical care provider directly for services
  • Files claim to be reimbursed by the Plan

An Individual can seek care from any doctor or hospital and receive benefits.

Hospital precertification is required for some services in order to receive the highest level of benefits.

This plan:

  • Pays reasonable and customary deductible coinsurance amounts, up to an out-of-pocket maximum
  • Rely on Utilization Management to control costs

Health Maintenance Organization (HMO) – An HMO provides prepaid benefits for most health care needs with no bills or claim forms. It provides services through a selected group of doctors, hospitals and other providers who are under contract to the HMO. To choose an HMO option, an individual must live or work in an area supported by the HMO network – as defined by their home ZIP Codes.

  • An individual choose a Primary Care Physician (PCP) from a list of physicians
  • They pay copayment (instead of deductibles) each time they visit a provider
  • Services rendered by the PCP or from a provider referred by PCP is reimbursed
  • HMOs provide preventive care and rely on Utilization Management to control costs

Preferred Provider Organization (PPO) – A PPO is a network of contracted participating physicians and hospitals that agree to render their services at discounted rates.

PPOs maintain networks of participating doctors and hospitals; however, individuals are not required to choose a PCP to coordinate their care. They have the choice of using in-network and out-of-network providers, using in-network providers offers higher benefits though.

Point of Service Plan (POS) – POS Plans have networks of participating doctors and hospitals that provide medical care at negotiable rate.

  • Individuals living in a POS service area, according to their home ZIP Codes, are eligible to join the plan and must choose an in-network PCP or facility from the list of providers
  • Using in-network providers offer the highest level of benefits

Exclusive Provider Organization (EPO) – EPO Plan resembles to HMO. Benefits are provided within a specific contracted network of physicians and hospitals with no out-of-network benefits available.

  • Individual chooses a PCP from the list of physicians
  • Individual are required to pay a predetermined copayment (instead of a deductible) each time they visit a provider.
  • Services rendered by PCP or by a provider referred by the PCP will be reimbursed
  • EPOs provide preventive care and rely on Utilization Management to control costs
About Author
Shaun Mike is a widely acclaimed writer on topics related to insurance. Health Insurance in Virginia is his forte and he writes extensively on topics received with great admiration by readers.

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