How is my Plan Structured?

Whether you are enrolled in a group or individual plan, understanding the way your plan works can help you use your benefits.

  • Health Maintenance Organization (HMO) or Exclusive Provider Organization (EPO) plans provide medical services in a specific geographic area, based on contracted rates with the providers paying a fixed and predetermined fee. HMOs require that you select a primary care physician (PCP) who is responsible for managing your health care. If you need a diagnostic service or care from a specialist, your PCP must provide you with a referral to a network provider. If you choose to go to a doctor outside of your HMO’s network for scheduled care, you may have to pay all of the cost (with the exception of emergency care which requires that you notify the insurance company after the fact).
  • Preferred Provider Organizations (PPO) and Point of Service (POS) provide coverage similarly to members through a pre-defined network of health care providers but are generally more flexible than HMOs. For example, you are not required to have a referral to see an in-network specialist. However, when you choose to go out-of-network for services, you are responsible for paying the difference between what the plan has determined to be their negotiated rate and what the provider charges.
  • High Deductible Health Plan (HDHP) A high deductible health plan has lower premiums and higher yearly deductible than a traditional health plan. These plans appeal to healthy people who cannot or don’t want to pay large monthly premiums for benefits. Preventive care is covered before the deductible, but most services must be paid by the insured until the deductible is met.
  • Health Savings Account (HSA) One advantage of a HDHP is the ability to contribute a certain amount of pre-tax dollars to a Health Savings Account in your name. Money deposited into your HSA that are unused for medical expenses remains in the account, earn tax-free interest and can roll-over year to year. Most people use the savings from lower monthly premiums and deposit them regularly into their HSA so they accumulate money to pay for the costs of medical care until the deductible is met and insurance coverage begins.
  • Government-sponsored plans like Medicare, Medicaid or military benefits frequently operate under alternate or a combination of structures. Many Medicare Advantage plans and Medicare Part C plans are structured as HMO or PPOs. Medicaid can also have a lot of variety in its plan types, but numerous states are implementing an HMO structure.

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