Health Insurance Plans
Health care in America is changing rapidly. Twenty-five years ago, most people in the United States had indemnity insurance coverage. A person with indemnity insurance could go to any doctor, hospital, or other provider (which would bill for each service given), and the insurance and the patient would each pay part of the bill.
But today, more than half of all Americans who have health insurance are enrolled in some kind of managed care plan, an organized way of both providing services and paying for them. Different types of managed care plans work differently and include preferred provider organizations (PPOs), health maintenance organizations (HMOs), and point-of-service (POS) plans.
You've probably heard these terms before. But what do they mean, and what are the differences between them? And what do these differences mean to you?
Health insurance coverage varies greatly, but basically it is a type of insurance policy that pays a pre-negotiated percentage of a policy holder's covered medical treatments. Do you really need health insurance or can you live without it? The answer depends on whom you ask and the question is not always an easy one.
Why Do You Need Health Insurance?
Today, health care costs are high, and getting higher. Who will pay your bills if you have a serious accident or a major illness? You buy health insurance for the same reason you buy other kinds of insurance, to protect yourself financially. With health insurance, you protect yourself and your family in case you need medical care that could be very expensive. You can't predict what your medical bills will be. In a good year, your costs may be low. But if you become ill, your bills could be very high. If you have insurance, many of your costs are covered by a third-party payer, not by you. A third-party payer can be an insurance company or, in some cases, it can be your employer.
Like other forms of insurance, health insurance doesn't really become an issue until you need it. Automobile insurance doesn't do you any good until you get into a car accident. Life insurance doesn't do you any good until you die. And health insurance doesn't do you any good until you need medical assistance. If you believe in Murphy's Law—that whatever can go wrong, will—then you probably should consider getting health insurance.
In some countries, health insurance is not offered by private companies like it is in the United States. In England, France, Canada, Sweden and Norway, for example, the doctors and hospitals are reimbursed by the government instead of an insurance company.
Types of Health Insurance
In the US, health insurance differs in two main ways:
Health insurance plans are usually described as either indemnity (fee-for-service) or managed care. These types of plans differ in the level of services provided, as well as the costs incurred.
With any health plan, however, there is a basic premium, which is how much you or your employer pay, usually monthly, to buy health insurance coverage. In addition, there are often other payments you must make, which will vary by plan. In considering any plan, you should try to figure out its total cost to you and your family, especially if someone in the family has a chronic or serious health condition.
Indemnity and managed care plans differ in their basic approach. Put broadly, the major differences concern choice of providers, out-of-pocket costs for covered services, and how bills are paid. Usually, indemnity plans offer more choice of doctors (including specialists, such as cardiologists and surgeons), hospitals, and other health care providers than managed care plans. Indemnity plans pay their share of the costs of a service only after they receive a bill.
- Indemnity Plans give members freedom of choice in doctors, services, and hospitals used, but at a cost.
- Managed Care Plans are much more economical, but offer limited predefined treatment options and procedures.
Managed care plans have agreements with certain doctors, hospitals, and health care providers to give a range of services to plan members at reduced cost. In general, you will have less paperwork and lower out-of-pocket costs if you select a managed care type plan and a broader choice of health care providers if you select an indemnity-type plan.
Managed Care Plans fall into three sub-categories. All are essentially networks to provide contracted services by specific providers at contracted prices:
- HMO: Health Maintenance Organizations are prepaid plans in which members pay a fixed monthly fee, regardless of how much medical care is needed in a given month. HMOs provide medical services ranging from office visits to hospitalization and surgery, and usually insist that you stay within the network when you need services from physicians and hospitals.
- PPO: Preferred Provider Organizations are groups of doctors and hospitals that provide medical service only to specific groups. PPO members typically pay for services as they are provided, and the PPO sponsor typically reimburses the member for the cost of the treatment. In most cases, the price for each type of service is negotiated in advance by the healthcare providers and the PPO sponsor.
- POS: Point of Service plans are not as common as the other two. This is a type of managed healthcare system in which you pay no deductible and usually only a minimal co-payment when you use a healthcare provider within your network. You also must choose a primary care physician who is responsible for all referrals within the POS network. If you choose to go outside of the network for healthcare, you will be subject to excess charges or deductibles.
The other main difference that defines your choice of plans is where or how you get your insurance. The main types include:
- Group Policies. You may be able to get group health coverage—either indemnity or managed care—through your job or the job of a family member. Many employers allow you to join or change health plans once a year during open enrollment. But once you choose a plan, you must keep it for a year. Discuss choices and limits with your employee benefits office.
- Individual Policies / family plans. If you are self-employed or if your company does not offer group policies, you may need to buy individual health insurance. Individual policies cost more than group policies.Some organizations—such as unions, professional associations, or social or civic groups—offer health plans for members. You may want to talk to an insurance broker, who can tell you more about the indemnity and managed care plans that are available for individuals. Some States also provide insurance for very small groups or the self-employed.
- Government Entitlement Programs. Medicare and Medicaid are government sponsored insurance programs for special situations.
- Medicare. Americans age 65 or older and people with certain disabilities can be covered under Medicare, a Federal health insurance program. In many parts of the country, people covered under Medicare now have a choice between managed care and indemnity plans. They also can switch their plans for any reason. However, they must officially tell the plan or the local Social Security Office, and the change may not take effect for up to 30 days. Call your local Social Security office or the State office on aging to find out what is available in your area.
- Medicaid. Medicaid covers some low-income people (especially children and pregnant women), and disabled people. Medicaid is a joint Federal-State health insurance program that is run by the States. In some cases, States require people covered under Medicaid to join managed care plans. Insurance plans and State regulations differ, so check with your State Medicaid office to learn more
Over time, the distinctions between these kinds of plans have begun to blur as health plans compete for your business. Some indemnity plans offer managed care-type options, and some managed care plans offer members the opportunity to use providers who are "outside" the plan. This makes it even more important for you to understand how your health plan works.
Which of these types of health insurance is right for you will depend on your personal situation. Choosing health insurance coverage is a time-consuming task and it can certainly be frustrating, but it's something that everybody needs to consider sooner rather than later.