Group Health Insurance

HMO, PPO, and POS plans are managed health care insurance plans that are replacing the more expensive fee-for-service or indemnity coverage. Hospitals, doctors and other health care providers have agreed to charge less to be included as "preferred" or "network" members. For employees, health insurance is definitely a good deal, especially if your employer pays a large chunk of the premiums. However, gone are the days when you could drop in on your family doc to socialize and have a few optional tests just to make you feel better.

Health Maintenance Organizations (HMOs) provide comprehensive pre-paid medical care. Your primary doctor (usually you can choose one within the preferred group) is the gatekeeper who controls your visits, tests, and access to specialists. Premiums are often less since the insured population is typically younger and healthier. There are no insurance forms and care is generally efficient. HMOs now attract excellent physicians, but the doctors as well as the nurse practitioners tend to be busy. Remember, they get paid whether you are ill or not. Emphasis is on prevention, so well-baby care, physical exams, and diagnostic tests are well covered. There are various types of HMOs including Independent Practice Associations (IPAs), but all provide comprehensive care by a closed group of providers.

Preferred Provider Organizations (PPOs) arose when employer-backed insurers negotiated significantly lower fees with a network of preferred health care providers. These lower fees are termed "usual, reasonable and customary,". You still need a gatekeeper physician to map out your care. Generally, these doctors see PPO and non-PPO patients in their own offices or clinics. They charge the agreed fee schedule for PPO subscribers. There may be forms to fill out or other small fees,but service is generally good and patient satisfaction tends to be higher than with HMOs because of the flexibility. Seeing out-of-network doctors will cost you more. For example, your plan might pay the preferred doctor 80% of the usual and customary fee(with your coinsurance payment being 20%) but only, say, 50% if you see an out-of-network doctor. The short hand for this arrangement is 80/50. But remember that the out-of-network doctor isn't bound by your plan's fee schedule, so the PPO 50% payment will be only for that fraction of the "usual and customary." You'll pay the overage.

Point-of-service (POS) plans combine features of both HMOs and PPOs. They may have two tiers of preferred doctors, one of which accepts the insurance reimbursement as payment in full, another which accepts 80% (or some other percentage depending on your plan) with your co-payment of 20%. If you elect to see out-of-network doctors, the reimbursement is only 50% (or some other percentage depending on your plan) of the mandated fee. The reimbursement fractions would be coded as 100/80/50. This is 100% for first tier preferred doctors, 80% for second tier and 50% for out-of-network doctors.

An Exclusive Provider Organization (EPO) is a type of PPO which requires the insured to use only the listed providers or to otherwise forfeit benefit reimbursement altogether.

Richard Whitaker Insurance Services rates the plans, advises you which are the most popular in your area, and helps you choose among the options including the deductible, maximum benefits, out-of-pocket limits, hospital coverage, out-patient and emergency care, maternity benefits, mental health including alcohol and drug treatments, dental, home health care, etc.

Please note that Richard Whitaker Insurance Services prefers to sell Health Insurance only in the States of California, Arizona and Oregon.