PPO

Health care institutions of the US are represented by various associations. Many health care clinics are privately owned, and only 21% of them belong to the government. As reported by the world health organization, the US is the leader of the world’s spend on health care in comparison to any other country in the world. The US healthcare system stands out among other progressive countries of the world. It is one of the rare countries, which doesn’t have a universal health care system. Additionally, the US has no universal health care insurance, and they recently enacted regulation, making health care coverage mandatory for almost every citizen.

A high price is one of the main reasons why most Americans find it troublesome to access a decent health service. Those who have a relatively low income have declared that they prefer not to:

visit a doctor when they feel sick
get a test when recommended
have a routine dental checkup
fill a prescription

A health maintenance organization now requires anyone to select a PCP – primary care provider – a physician who practices general medicine and will be a gatekeeper for the patient. As a rule, they are the first to be visited in case of an undiagnosed disease and in order to get further instructions. They collect primary symptoms, provide a physical examination and treat common illnesses. In case of a serious disease, they direct the patient to a certain specialist and provide the list of necessary procedures to follow (e.g.: blood tests, scannings, etc.). After all necessary data is collected, the PCP comes up with a diagnosis and recommendations on treatment, diet, and general patient’s habits for correction.

Before You Start Any Health Care Plan

Before you choose any program, take your time to read the policy description and pay attention to the details. Don’t hesitate to ask as many questions as possible, until you clearly understand your coverage.

Ask your agent the following questions:

Can I select any doctor, pharmacy or hospital for my personal preference?
Does the plan cover 100% of all my prescribed medication?
Does the insurance cover dentists’, dermatologists’ and eye doctors’ services?
According to my plan, are special conditions covered (e.g.: psychiatric care, physical therapy or pregnancy)?
Is home care covered by this insurance plan?
Do I have to make any co-payments?
Are there any disputes about bills and services? How are they regulated?
What is the maximum sum I have to pay to cover costs out of pocket?
What is the percentage of deductibles?

N.B.: Deductibles mean a certain amount of money a patient pays before the insurance company pays their claim. Do not confuse deductibles with co-payments. These are the payments you make when you get a prescription or receive medical services.

Which Health Insurance Plan to Choose

Below the most popular insurance programs. At first glance, their names may seem to be an alphabet soup, but after a few minutes of analysis, you will realize the main differences between them and the essential benefits of each plan.

HMO

Health Maintenance Organization plans offer a wide choice of services for patients. You are likely to be insured for a wide range of health services as compared to other coverage plans. As soon as you subscribe to their services, you will have to choose a Primary Care Physician (PCP), who will generally take care of your treatment and prescriptions. Other specialists are available only after receiving a referral from your PCP.

Generally, those who opt for this kind of insurance, have lower expenses and minimal co-payments. You are not obliged to submit your own claims to the insurance company. Please note you will not receive coverage if you use services of an out-of-network professional or if you get any service without your physician’s recommendation.

Preferred Provider Organization plan is a type of insurance with “preferred” providers within your location. They will not obligate you to choose a PCP and you will not need a referral for seeing a specialist. Here you will only have to pay a certain amount of a total bill according to your plan. In case you visit a specialist out of the recommended network, you will pay a larger part of your final bill than you would have to pay if you visited a preferred doctor in your network. But still, a certain percentage of your expenses will be covered. Co-payments for services generally vary between $10 and $30.

POS

Point of Service is a combination of two plans: HMO and PPO. Here, you will have to get a referral from a physician to receive any special treatment. But, you will get more coverage in case you visit hospitals and doctors within your network. You will, however, be less insured if you get any service form the providers out of your network. You may also have additional co-payments and deductibles on a yearly basis.

EPO

Exclusive Provider Network also has some similarities with PPO and HMO plans. As a rule, EPO is a more flexible plan than an HMO, and it is cheaper than a PPO. When you stick to this type of insurance, keep in mind that you don’t need PCP’s referrals. As with an HMO, you will have to pay out of your own pocket if you choose a doctor who provides services outside of your network. EPO is a great option if you want to see a specialist without a referral from your general physician.

Other Items to Consider

Other specific plans include Long-Term Care service (LTC). This is valuable for older people concerned about potential chronic illnesses.

Catastrophic Health plans are aimed to support people in case of unexpected health issues in case of an emergency.

People with disabilities can take advantage of special government programs to get help with their health needs. These programs differ depending on the location, so it is necessary to consult local officials for more information.

Health insurance is a policy coverage that provides the policy holder with the financial protection in the event of an illness. It helps cover medical expenses. The U.S. federal government provides health insurance to those people who cannot afford health care coverage with other insurance companies. This health insurance coverage is categorized into Medicaid and Medicare. Medicaid provides health insurance to low income families and individuals and it covers basic health services and hospital visits. Medicare is covered through your payroll and provides health insurance to people who are over 65 years of age or those who are below 65 years but with disabilities.

How U.S. Health Insurance Works

Health insurance begins by paying an upfront premium by the consumer which is intended to help share the risk of healthcare costs with a wide range of other individuals. Other costs that come with most health insurance plans in the US are captured as copays, coinsurance and deductibles. These costs represent the share the insured pay out of their pockets when they receive health care. Deductibles are what the consumer pays before the insurance company contributes. A copayment is what the insured pays for each visit. Coinsurance is the percentage the consumer pays for procedures like surgeries or hospital stays.

HMO: Health Maintenance Organizations

The Health Maintenance Organization plan is an insurance plan that provides preventative care coverage for both the enrollee and his/her family. It covers doctor’s visits, hospital stays, emergency care, surgery, laboratory tests, x-rays, and therapy. This plan limits the choice of doctors and hospitals since the enrollee chooses one doctor to provide health care and, therefore, are required to get a referral from their doctor to see a specialist.

PPO: Preferred Provider Organization

These insurance plans mostly cover preventative care. They require the insured to choose a doctor to be their primary doctor who in turn monitors their health. For the Preferred Provider Organization, the insured often has to pay a small amount as co-payment for each time they visit the doctor.

The Obama Healthcare Plan

Obamacare, also known as the Affordable Care Act, aims at providing more people in the U.S. access to health care, holding insurance companies accountable for their decisions as well as protecting patients from being denied coverage. This plan is able to pay for itself since it requires that everyone get health insurance or else pay a tax. This plan allows those with chronic illness or pre-existing illnesses to get treatment after the expansion of Medicaid. This plan also has subsidized prescriptions for those who are in Medicare.

Factors to consider when selecting health insurance in the U.S.

Insurance companies in most cases have a contract with some health providers and hospitals to supply services to those who have an insurance plan with them at an affordable price. This is how insurance companies reduce their costs. Therefore, when evaluating an insurance coverage, a person should first consider which health provider and hospitals have a contract with the insurance company. An enrollee who goes outside of the network of health providers who have contracted with the insurance company is required to pay more for their medical care.

Secondly, a person should consider what the insurance plan covers since some insurance plans do not cover certain pre-existing conditions. Although the Affordable Care Act introduced more standardization to insurance plan benefits, not all were standardized.

Finally, consider how much an insurance plan costs since with some insurance plans, premium payments are only part of the incurred cost. In order to receive healthcare under some insurance plans, one incurs some other costs from their own pockets in form of copayments, deductibles, coinsurance and copays.

Importance of health insurance in the U.S.

With the introduction of Obamacare, there are now opportunities for all citizens to find affordable healthcare options. If you have a pre-existing condition or a chronic illness, through the Affordable Care Act (Obamacare), you are no longer at risk of an insurance company canceling your coverage. This is a significant benefit as often those dealing with a pre-existing condition are the most in need of healthcare insurance.

Healthcare has become more affordable for the policy holders since they are able to negotiate services on behalf of a large contingency of people. This, in turn reduces the cost to each individual. Preventative services including vaccines, checkups and screenings are available at low costs (or sometimes free) without any deductible cost. There are additional avenues as well to help with the costs of your health insurance.

Finally, having health insurance coverage exempts one from paying penalties in the form of taxes which are levied against those who do not have a health insurance plan under the Affordable Care Act.

Due to the ever increasing costs of health care, it’s important to understand the different options available to you. Illnesses are very unpredictable and it’s impossible to predict you might get sick or injured. It’s also hard to determine how much health care you might need and how much it might cost to get medical attention. However, health insurance takes care of these unpredictable issues and offers a way control these costs at a known and fixed amount each month. Although health insurance may seem expensive since premiums are not the only costs that come with the insurance coverage, it is better to incur these costs when one is healthy and pay less when in need of medical attention.

Tag: PPO

Health Care Options in the U.S.