Health Insurance - PPO HMO INDEMNITY - What are they?

Health Insurance Policy Options

This is from Path2USA

Insurance Plan:
There are three kinds of medical insurance you can get viz. HMO, PPO and POS plan. The basic difference between these plans is the cost, and the flexibility in choosing a physician.

1. What is HMO?
HMO stands for Health Maintenance Organization. HMO is a company that offers health plans, which provides medical care from an approved network of doctors, hospitals, and pharmacies. The patient needs to pay some set minimum fee per visit. These fees are usually much lower than PPO (Preferred Provider Organizations).

Advantages of HMO:

Nil or very low deductibles.
Comprehensive benefits.
Preventive care is often good.
Disadvantages of HMO:

HMO plan includes only a particular chain of hospitals and doctors.
The patient must see doctors within the network.
The patient must get permission from the primary physician to see a specialist, or the HMO may not pay for the services.
HMO's often refuse to pay for the emergency visits, if they don't consider it as a true emergency.
2. What is PPO?
PPO stands for Preferred Provider Organization. PPO allows patients to see a specialist without a referral from a Primary Care Physician. They have a wider range of doctors to choose from. The direct access to specialists is good for people who have chronic illness, or in case of urgent care and emergencies. Patients can get appointments with their preferred specialists as and when required.

Usually, a PPO will pay a greater percentage of the cost for a preferred provider, and less for a non-preferred provider.

Advantages of PPO:

Patient can visit any doctor and hospital. They are categorized as preferred and non preferred providers.
PPO covers all preferred providers according to their policy.
Disadvantages of PPO:

For all non preferred providers PPO covers only 80% of all the expenses, depending on your insurance company rules. And rest has to be paid by you.
3. What is POS?
POS stands for a Point of Service plan, which combines the cost savings of a HMO with the flexibility of a PPO. Find out the details and rules from your medical insurance company.

FAQ?

What to do after you get a HMO plan?
Once you've signed up and received your HMO plan, be sure to read your policy thoroughly and carefully. You should know answers to questions like:

Which doctors, hospitals you may see
What procedures are covered and what aren't
How are emergency visits handled? And what procedure you must follow to get the full coverage
What kind of cases come under emergencies (As they may deny coverage, if they don't consider your problem as an emergency.)
What is the co-payment cost (i.e. How much you will have to pay per visit?)
Find out the procedure for claims, if any.
What to do after you get a PPO plan?
Always find out which doctors and services are considered preferred and which are non preferred.
It is always better to go to the preferred providers, as the PPO plan would give full coverage for them. You will only have to pay for the co-payment. But for a non preferred provider, your co-payment is quite higher compared to the preferred provider.
Always read your policy very carefully.
Find out the procedure for claims, if any.
What is a Primary Care Physician?
A primary care physician manages your entire health care program. One has to first visit his/her primary care physician for any kind of medical problem. In case you require a specialist, then your physician should refer you to a concerned specialist.

Can I change my primary care physician?
Yes, one can change his/her primary care physician maximum once a month. But it is always better to stick to one physician. Find out the rules form your insurance company. Normally to change, you will just have to call up the new physician you want to be your primary care doctor, and then inform your insurance company about the change.

What is a Chart Number?
This number is given to each patient, and it refers to a file which has all the records of your prior tests, ailments, etc. This number makes it easy for the person at the reception to make your future appointments and is also a reference for your doctor. You will be required to provide your chart number whenever you call or visit a doctor.

What is difference between Urgent Care and Emergency Services?
Taking appointment for any ailment is a time taking process, hence every hospital provides urgent care and emergency care services. These are the quick medical care services provided by almost all medical centers.

Emergency services are those services required as a result of unforeseen injuries or acute illness, for which a delay in treatment would result in a permanent physical impairment, or loss of life. Such as heart attacks, strokes, poisonings, sudden inability to breathe etc.

On the other hand, urgent care includes less serious medical conditions which require immediate attention. Such as fever, fractured bone, any cuts which require immediate attention, etc.

** Note: Always make sure from your insurance company as to what situations are treated as urgent and emergency. If possible, it is better to contact your primary care physician in an urgent situation and arrange for your immediate care.

What are Preferred and Non Preferred providers for a PPO plan?
PPO is a network of physicians that have agreed, by contract, to discount their rates for the respective PPO members. These physicians, specialists are known as preferred providers, and PPO members are free to see any of them, without any reference from their primary physicians.

PPO members may also see non-contracted providers, these are known as non preferred providers. The co-payment fee for seeing a non preferred provider is generally higher than the preferred providers.

How to get medicines from a pharmacy?
Read your insurance company's manual to find out which are the pharmacies included in your plan. Select the nearest pharmacy to your place. For all prescribed medicines, you will have to pay the minimum fee, and rest will be covered by your insurance. But your insurance won't cover other medicines, which can be picked directly off the shelf from the stores.