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There are two types of health care plans on the market - indemnity plans and managed care plans. An indemnity health care insurance plan is becoming less popular as they generally require you to pay upfront for services and submit a claim for reimbursement, plus they generally end up costing you more money in the long run. Managed health care insurance plans are much more common and are explained in the next section.
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Managed Health Care Plans
There are three types of managed health care plans and they are briefly explained below:
- PPO, or Preferred Provider Organization, healthcare insurance plans encourage you to use their network of preferred physicians and facilities that have negotiated discounted rates to provide service to policy holders. You will be able to see any doctor in the network without first needing to get a referral, but you will most likely have an annual deductible you need to satisfy and have copayments or coinsurance for certain services. While you can seek care outside of your network, this will result in higher out-of-pocket costs for you.
- HMO, or Health Maintenance Organization, healthcare plans require you to have a primary doctor that will take care of the majority of your medical needs and will give you referrals to specialists if necessary. Your out-of-pocket costs are generally lower with an HMO, as you might not have a deductible or copayments, but you likely will not have coverage from a specialist or out-of-network doctor without a referral from your primary doctor.
- POS, or Point of Service, healthcare plans combine some features of an HMO with some features of a PPO. You have to choose a primary care doctor whose coverage is not subject to a deductible, but you may be subject to a deductible if you seek care outside of your network. A POS offers some of the flexibility of a PPO with some of the cost savings associated with an HMO.
When it comes to choosing a health care insurance plan, you need to decide if flexibility in choosing a doctor is more important, or cost savings is what interests you the most. eHealthInsurance makes it easy to compare different healthcare insurance plans and see which has the benefits you desire the most.
Health Care Insurance Plan Quotes
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Take advantage of eHealthInsurance's advanced technology to research, analyze and apply for the healthcare insurance plan that best fits your needs, all for free! Get your FREE, no-obligation quotes instantly from eHealthInsurance to see which health care plans are best for you.
How Health Insurance Works
Below is a video from eHealthInsurance using a hypothetical scenario to help explain how health coverage works.
Managed Care Plan Types Compared
| HMO | POS* | PPO | |
| Low Flexibility - HMOs (Health Maintenance Organizations) have the least amount of flexibility of the three managed care plan types as they require the insured to have a primary care physician who refers them to any other medical professionals. Care is all within the network of doctors that have contracted with the health insurance provider - this limits the provider options. If a medical professional or facility is not within the network, the insured will not have medical coverage if they choose to use them (unless it is an emergency). |  |  | |
| Moderate Flexibility - POS (Point of Service) plans are more flexible than the HMO plans, but not as flexible as the PPO plans. POS plans are a hybrid of both HMO and PPO, with the main component being a referral and co-pay based plan like an HMO where a primary care physician is picked, who then refers the insured to in-network medical professionals, and the insured is responsible for co-pays up to an annual out-of-pocket amount. A POS has an out-of-network option that is deductible, non-referral based that allows the insured to choose where to receive care, but expenses are out-of-pocket until the annual deductible limit has been met. This gives an option to a person that doesn't want to be locked into a totally referral based structure that an HMO provides. | | | |
| High Flexibility - PPO (Preferred Provider Organization) plans are the most flexible of the three managed care plan types. There is no referral necessary to see a medical professional, which means the insured can seek care from whomever they wish, including both in-network and out of network providers. Costs will generally be lower for in-network providers, as the medical professionals have a contractual obligation to provide care at a negotiated rate. While care can be sought outside of the network, the insured will be faced with higher annual deductible amounts, possibly higher co-insurance amounts, and generally overall higher costs. | | | |
| In-Network Only - Healthcare must be received from a medical professional that is part of the network that contracts with the insurance provider. This network of medical professionals has a contract with the insurance company that states they will provide services for a set rate (depending on the service rendered), thus providing care at a discounted rate. If care is received from a medical professional outside of the network, the insurance provider most likely will not pay for the coverage (except for cases of emergencies). | | | |
| In & Out of Network - The insured may seek medical care within a network of healthcare professionals that have contracted with the insurance provider to provide care at a reduced cost. The insured may also seek medical care outside of the network, but their out-of-pocket expenses will be higher as care is not provided at a reduced rate. Maximum annual deductibles will be higher for out of network providers, greatly increasing the costs to the insured, giving them incentive to only seek care from an in-network provider. | | | |
| Referral Based - The insured must pick a primary care physician who provides referrals to other medical care professionals as needed. If you see a specialist without a referral, your costs most likely will not be covered by the insurance provider. | | | |
| Non-Referral Based - The insured does not need a referral to seek medical treatment from a healthcare professional. They may see whomever they wish, though it is in their best interest to see in-network providers to keep their costs low. | | | |
| Co-Pay Based - The insured is responsible for co-pays (for office visits and medical procedures) until an annual maximum out-of-pocket expense limit is reached, at which time coverage is paid for 100% by the insurance provider. | | | |
| Deductible Based - The insured pays for care out-of-pocket (at rates negotiated by the insurance company) until an annual deductible is met, at which time the insurance company starts to pay. Once the deductible is met, there may be a co-insurance amount (up to an annual maximum), which is a percentage of the bill the insured pays, such as 20%, where the insurance company picks up the tab for the rest. Depending on the plan, you may have a co-pay for certain things such as doctor office visits, though many PPOs don't use a co-pay. | | | |
| Low Cost - An HMO typically is the least expensive health coverage option, but gives you the least flexibility. | | | |
| Moderate Cost - A POS plan's price usually comes in somewhere between that of a comparable HMO and PPO. This is because it offers a bit of the benefits of both, while trying to contain costs. People looking for the low cost benefits of an HMO, yet a bit more flexibility (like a PPO) should consider a POS plan. | | | |
| Higher Cost - A PPO plan is the most flexible, but is usually the most expensive. You pay for the ability to pick and choose your medical professional, without being locked down to a primary care provider. If flexibility is what you want, you will pay a higher monthly premium. | | | |
*POS Plans - The most popular type of managed care plans are HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations). POS plans, while available, are not as common as the other two, so as you are comparing plan benefits and costs via eHealthInsurance's website, don't be surprised if all you see are HMOs and PPOs.
