ABC’s of Health Insurance: From HMO to PPO

With the spotlight on coronavirus, medical care and the means to pay for medical care become ever important. Just one visit to the doctor averages $200-$600, and hospitalizations cost anywhere in the tens to hundreds of thousands of dollars! Most people do not have that kind of money laying around, and even if you do, would you want to spend it all on medical bills? Health insurance allows you to pay only a fraction of the cost of medical care, while the insurance company pays the rest. Like any other insurance, you pay on a regular basis for the insurance, no matter if you are sick or healthy. But in the event that you require medical attention, the cost of care won’t become a huge burden to your finances.

The case for having health insurance can be a topic of debate, with some countries mandating universal health care through public funding and taxes and others leaving the decision up to the individual. Given the cost of medical care nowadays, the case for having health insurance seems like an easy choice. What’s not so easy is deciphering the language of health insurance, especially when deciding which insurance plan to choose. Use the glossary below to help you “talk the talk” of health insurance!

Glossary

  • Coinsurance: The percentage (%) you owe for medical services. If your coinsurance is 20%, you pay $50 of that $250 medical bill (or 20% x $250).
  • Copay: The fee per doctor visit. A $25 copay for an office visit means you only pay $25 for the visit, instead of the full rate. Some insurance plans use a copay for urgent care visits and ER visits too.
  • Deductible: The amount you pay before insurance benefits kick in. For example, if you have a $1,000 deductible along with 20% coinsurance on a medical procedure that costs $5,000, you pay a total of $1,800 = $1,000 deductible + $800 coinsurance ($4,000 remaining x 20% coinsurance). Ever hear of high-deductible health plans (HDHP)? That means the deductible is higher than normal, usually starting in the thousands of dollars.
  • EPO: Exclusive Provider Organization, or EPO, is a type of health insurance plan that restricts all medical benefits to network providers and hospitals. Any care sought outside of the network will not be covered.
  • HMO: Health Maintenance Organization is another type of health insurance plan that adds more restrictions, but offers lower medical costs like little or no deductible and lower coinsurance. The main difference between an HMO plan and EPO/PPO plan is that the HMO typically requires a referral from your primary doctor to see anyone else for a medical problem. In an effort to keep costs low, it is rare that you will ever be referred out-of-network, so when choosing an HMO, make sure you are comfortable with the network of providers and hospitals.
  • HSA: Health Spending Account, or HSA, allows you to save money from your paycheck to be used solely for medical expenses (cannot be used for premiums). The benefit to using an HSA vs. paying from your own pocket is that money saved in an HSA never gets taxed. For instance, if your income tax is 13%, only $1 of every $1.15 earned goes in your pocket. Fifteen cents ($0.15) goes to taxes. Putting that money in an HSA means you get to keep the entire $1.15, but only spend it on health care.
  • In-Network: These are the preferred providers for your insurance plan. In-network providers and hospitals charge a lower copay or coinsurance than out-of-network options. With HMO and EPO plans, your benefits may not even extend beyond in-network providers, so seeking care outside of the preferred provider directory would mean paying for medical expenses on your own.
  • Out-Of-Network: Health insurance companies require you to pay more to see out-of-network doctors and hospitals. In the case of HMO or EPO, you will likely pay the full rate to seek out-of-network care, since no insurance benefits apply.
  • Out-Of-Pocket Max: Once you spend the out-of-pocket maximum for the year, the insurance will take over all expenses beyond that limit. Let’s say your out-of-pocket max is $3,000 in a given year, once you have paid $3,000 in medical expenses that year, the insurance will pay any remaining or future medical expenses for the year.
  • PCP: Primary Care Physicians, or PCP, are the doctors who provide general care like conducting annual physicals or treating common colds. They refer you to other doctors, or specialists, when the medical issue is beyond their scope. HMO plans usually require selecting a PCP, so all care must either be performed by or referred by the PCP.
  • PPO: Preferred Provider Organization, or PPO, is a type of health insurance plan that allows you to see any provider you choose, no referral necessary. It costs less to see in-network doctors compared to out-of-network doctors, but you have freedom of choice. This choice comes at a higher cost to you, which becomes noticeable in the deductible or coinsurance. If the PPO plan carries a low deductible or low copay and coinsurance amounts, you will likely pay a higher premium for that plan.
  • Premiums: The premium is what you pay on a regular basis for health insurance. If your employer offers health insurance, they usually pay a significant portion of the premium, and you are left with a smaller chunk of the premium. That is why when people leave or lose their jobs and elect to keep the health insurance plan (otherwise known as COBRA), they notice a spike in insurance premiums. The insurance company is not charging more. It’s just the combined cost of paying both employee and employer premiums.

Homework: What type of health insurance do you have? HMO, EPO, or PPO? Become familiar with the deductible, copay and coinsurance. How does the plan suit your needs?

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