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Health Insurance Guide

Health Insurance Guide

Health has always been uncertain. We can try our best to keep fit, but after a certain age the expenses on health do increase. Its better to keep ourselves insured under a Medical Plan to make sure that our medical expenses are taken care of.

If we talk about Individual Health Insurance Plans in US, they are designed to help an individual and their families access care and cover the medical cost of receiving medical services from any physician, hospital or other provider.

There are different types of Medical Plans:

IndemnityHealth Insurance Guide

Health Maintenance Organization

Preferred Provider Organization

Point of Service Plan

Exclusive Provider Organization


Health Insurance Portability and Accountability Act (HIPAA) Privacy Protected Health Information.

Under HIPAA Privacy, unauthorized individuals cannot ask or inquire about any clinical or personal health information when counseling participants about their Medical Plans.

Indemnity Plans These plans are sometimes called Free-for-Service Plans, where:

An individual pays the medical care provider directly for services

Files claim to be reimbursed by the Plan

An Individual can seek care from any doctor or hospital and receive benefits.

Hospital precertification is required for some services in order to receive the highest level of benefits.

This plan:

Pays reasonable and customary deductible coinsurance amounts, up to an out-of-pocket maximum

Rely on Utilization Management to control costs

Health Maintenance Organization (HMO) An HMO provides prepaid benefits for most health care needs with no bills or claim forms. It provides services through a selected group of doctors, hospitals and other providers who are under contract to the HMO. To choose an HMO option, an individual must live or work in an area supported by the HMO network as defined by their home ZIP Codes.

An individual choose a Primary Care Physician (PCP) from a list of physicians

They pay copayment (instead of deductibles) each time they visit a provider

Services rendered by the PCP or from a provider referred by PCP is reimbursed

HMOs provide preventive care and rely on Utilization Management to control costs

Preferred Provider Organization (PPO) A PPO is a network of contracted participating physicians and hospitals that agree to render their services at discounted rates.

PPOs maintain networks of participating doctors and hospitals; however, individuals are not required to choose a PCP to coordinate their care. They have the choice of using in-network and out-of-network providers, using in-network providers offers higher benefits though.

Point of Service Plan (POS) POS Plans have networks of participating doctors and hospitals that provide medical care at negotiable rate.

Individuals living in a POS service area, according to their home ZIP Codes, are eligible to join the plan and must choose an in-network PCP or facility from the list of providers

Using in-network providers offer the highest level of benefits

Exclusive Provider Organization (EPO) EPO Plan resembles to HMO. Benefits are provided within a specific contracted network of physicians and hospitals with no out-of-network benefits available.

Individual chooses a PCP from the list of physiciansHealth Insurance Guide

Individual are required to pay a predetermined copayment (instead of a deductible) each time they visit a provider.

Services rendered by PCP or by a provider referred by the PCP will be reimbursed

EPOs provide preventive care and rely on Utilization Management to control costs

by: Shaun Mike
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Health Insurance Guide