Understanding Health Insurance

Individual and family health insurance is a type of health insurance coverage that is made available to individuals and families, rather than to employer groups or organizations. Given the option, most people would prefer to have their employer provide group health insurance coverage. InsureOne Benefits offers access to a variety of individual and family health insurance options.

PPO Plans

Members of PPO (Preferred Provider Organization) plans are encouraged to use the insurance carrier’s network of doctors and hospitals. These healthcare providers are contracted to provide services to the plan’s members at a discounted rate. Choosing a primary care physician (PCP) is not generally required with a PPO plan and you’ll typically be able to use service providers within the network at your own discretion.

You will most likely have an annual deductible to pay before the carrier covers your medical bills. You could also have a co-payment for dome services, or be required to pay for a specified percentage of the total amount of your medical bills.

With PPO plans, services provided by an out-of-network physician are usually covered at a lower percentage than those provided by an in-network physician.

Co-payments

A co-payment, or co-pay, is a specific charge that your health insurance plan may require you to pay for a medical service or supply. For example, your health insurance plan may require a $15 co-payment for visiting a doctor’s office or a prescription, after which the carrier often pays the remainder of charges.

Deductibles

A deductible is a specific dollar amount that your health insurance carrier may require you to pay out of your own pocket every year before your plan begins to make payments for claims. Not all health insurance plans require a deductible. HMO plans usually do not require a deductible, while most PPO plans do.

Coinsurance

Coinsurance is an insurance term referring to the amount you are required to pay for a medical claim, apart from any co-payments or deductible. For example, if your health insurance plan has a 10% coinsurance requirement (and does not have any additional co-payment or deductible requirements), a $100 medical bill would cost you $10, and the insurance company would pay the remaining $90.

In-network and Out-of-Network Providers

In-network providers are contracted with the health insurance company to provide services to their plan members at pre-negotiated rates. Out-of-network providers are not contracted with the health insurance plan. Therefore, if you visit a physician or other service provider who is in the network, the amount you will be responsible for paying will be less than if you had gone to a provider who is out-of-network. In many cases the insurance company will either pay less or nothing at all for services provided by out-of-network providers.

As a general rule, PPO and HMO plans make use of provider networks.

Choosing wisely

If you have a choice from more than one plan, compare how each plan handles the following:

Specialized Coverage

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