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Health Insurance Types of Coverage

With so many health insurance companies and types of insurance out there, finding a plan that meets your family's needs can be confusing. Price, benefits, and services available vary so it is important to research the types of coverage available before making your choice for a health care plan.

  1. HMO

    • Considered to be a managed health care plan, the Health Maintenance Organization (HMO) plan is generally less expensive than other types of coverage. Patients with HMO coverage choose a primary care physician (PCP) from a list of providers who are contracted by the insurance company. The PCP provides patients with preventative and maintenance health care and if a specialist is needed, the PCP will refer patients to one that is also contracted by the insurance company. HMOs set guidelines for contracted doctors to follow which generally limits the types of services that will be covered.

    PPO

    • A Preferred Provider Organization (PPO) is a type of insurance coverage that allows patients to choose the doctor they would like to see. Doctors and hospitals contract with the insurance company to accept lower fees for their services. These doctors are considered in-network. PPO plans require patients to pay a co-payment at the time of treatment and the insurance company generally pays 80 to 90 percent of the remaining fees charged from an in-network physician. If an out-of-network doctor is used, insurance companies will commonly pay much less. PPO plans also allow patients to refer themselves to a specialist without prior approval from their primary physician.

    POS

    • Point of Service (POS) insurance plans have characteristics of both the HMO and the PPO. POS plans require patients to choose a primary care physician (PCP) from a list of in-network doctors. If specialist treatment is necessary, patients may have their PCP refer them to an in-network specialist or refer themselves to an out-of-network doctor should they so choose. If the PCP refers a patient to an out-of-network physician, fees are generally covered partially or in full but if a patient refers themselves out-of-network, predetermined coinsurance fees may apply. With POS plans, patients choosing to be seen out-of-network must file their own claims and manage health care receipts for proper reimbursement.

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