Everthing You Need to Know About Individual Health Insurance Plans (Part II)

by: Jonathon James


In 'Every Thing You Need to Know about Individual Health Insurance Plans (Part I)', we began our discussion of individual health insurance plans by talking about indemnity plans. We then started a discussion about managed health care plans. We now continue that discussion…

A Health Maintenance Organization (HMO) plan is less expensive than a PPO and generally includes coverage for preventative care. Participants are required to pay a monthly premium, and a nominal co-payment each time they see a doctor. They must be seen by medical care providers that are part of the HMO network. These medical care providers have an agreement with the insurance company to perform various medical procedures at a previously negotiated and reduced rate. Participants are required to select from this group of providers a Primary Care Physician (PCP) and must always see their PCP first. To be seen by a specialist, the PCP must initiate a referral.

The disadvantage of an HMO is that participants are forced to choose a PCP from the HMOs approved list of providers and sometimes, their 'preferred' doctor is not on the list. The HMO typically won't cover the costs of medical care provided by professionals outside the HMO network. And because an HMO network is limited in size, it often takes a long time to get an appointment with the PCP.

A Preferred Provider Organizations (PPO) is similar to a HMO, except that there is no need to first be seen by a PCP. Participants are advised to choose a medical professional from the PPO's approved 'network' but they don't have to and they don't need a referral to see a specialist. Should a participant choose to go outside the network, their co-payment will generally be higher, the percentage that the PPO pays for the medical care will be lower, and they will likely have to satisfy a deductible. PPO plans have become the most popular individual health insurance plan in the U.S. today.

Although PPOs offer more freedom of choice, there are generally more costs involved in this type of managed care plan. These costs can be significant when participants go outside the network.

A POS or Point of Service managed care plan can be described as a cross between a HMO and PPO. It offers more freedom of choice like a PPO, and a lower cost like an HMO. Participants must designate a PCP, but even then it is difficult to get a referral to a specialist. When participants stay within the network, paperwork is minimal, and so are co-pays. Plus, there are no deductibles. Although they might sound like the best of both worlds, POS individual health insurance plans aren't very popular.

When considering a managed care plan, be sure to look closely at the list of in-network doctors. If you don't see your doctor listed, you may want to forego this option. Of course, if your health care is primarily yearly check-ups and the occasional antibiotics, and you do not have a physician preference, then this is an individual health insurance plan that could work for you. It will cover health emergencies, as well; there are just more hoops you have to jump through.

The many different types of available individual health insurance plans, as well as individual health insurance coverage, give you many options from which to choose when selecting coverage. Be sure to do your homework; becoming an educated consumer will help you decide on the best individual health insurance plan for you and your family.


About The Author

Jonathon James has been working in the health industry for nearly twenty years. To view additional articles and resources related to individual health insurance plans, please visit http://LearningAboutHealthInsurance.com.