Medical coverage choosing is important if you are to receive the kind of care you want at a cost you can afford. Generally, there are three kinds of coverage available for private purchase: HMO plans, PPO plans, and POS plans. Each should be examined and fully understood before proceeding with medical coverage choosing.
HMO Plans
"HMO" stands for "Health Maintenance Organization" and refers to health care plans that are largely self-contained. In HMO systems, all services are provided through the organization itself.
This approach has many advantages. The first is convenience. If you need a health problem addressed, you typically need not search for services, programs, or specialists in order to receive care. A second benefit is cost. HMO coverage is typically among the least expensive available, and bothersome claim forms are usually not required. Third, other support services (x-rays, lab tests, physical therapy, etc) are usually also easy to receive.
Key disadvantages: First, all services must be provided through the system - even some emergency services may not be covered if they are provided elsewhere. Second, you may not select your own medical provider. Rather, one will be assigned to you. Even then, you may still be seen by alternate providers when it is convenient to the system. Third, you may be denied specialist care, unless the system determines it is essential. Thus, cost savings versus reduced personal control are key factors in HMO medical coverage choosing.
PPO Plans
"PPO" stands for "Preferred Provider Organizations" and refers to a network of providers that have contracted to offer services under a particular health insurance plan. The benefits include: Greater flexibility in selecting a physician and the clinic or office where you will receive your care. Claim forms may not be required, or are greatly simplified. You may see a specialist without outside approval. You may even see a physician outside the network, although the level of coverage may then be reduced.
Key disadvantages: First, policy premiums may be more expensive, and services may only be covered on a percentage basis. Second, ancillary services (labs, x-rays, pharmacy, etc) and allied health services (respiratory therapy, physical therapy, counseling, etc) may not be covered and/or may be inconveniently located.
POS Plans
POS refers to a "Point of Service" or traditional fee-for-service health coverage. The greatest advantage of this plan is that you can select virtually any physician you want, anywhere, to provide your medical care. Specialist referrals, ancillary services, and allied health providers may also be obtained relatively easily.
However, POS plans are among the most expensive available. Further, you must use detailed claim forms, and you may even be required to pay the medical provider up front, and only later be reimbursed by the plan. Out-of-pocket expenses are also often higher, and the percentage of costs covered may be much lower. Therefore, flexibility versus high costs are key factors in POS medical coverage choosing.
Other Plans
COBRA plans are coverage options made available when you lose employer-based health insurance. College and university students may also be offered low-cost coverage options. Low-income individuals and families may also be eligible for state-sponsored coverage (Medicaid). High-risk individuals (i.e., those with pre-existing medical conditions) may need to select from among your state's pool of "Risk Providers".
Medical coverage choosing that meets your budget and personal needs can protect your family from catastrophic health care costs. However, making a well-informed choice can help you be pleased with the services you receive and the costs involved.
