Types of Health Insurance Policies
Guarantee Issue
A guarantee issue policy is one that cannot deny a group coverage for medical reasons. Service organizations such as Blue Cross and Blue Shield and Health Maintenance Organizations
are examples of a guarantee issue policy. The premium structure is based on the number of employees in the group, the area in which services will be provided and the industry of the
company. Premiums will be a fixed amount based on single, couple, and family.
Types of Plans
- HMO (Health Maintenance Organization)
- POS (Point of Service)
- PPO (Preferred Provider Organization)
- Traditional V. HMO
Health Maintenance Organization
In an HMO, your medical care is managed by a primary care physician (PCP). Your PCP becomes your personal physician, the doctor you see for routine medical care including annual physicals,
immunizations and health concerns. If you need to see a specialist, be admitted to a hospital, have lab or X-ray work done, your PCP will refer you to the appropriate provider or facility.
In an HMO, you are required to stay within the network in order to be eligible for benefits. At the time of service, you pay a small co-payment, keeping out-of-pocket costs low. With
no claim forms to complete, an HMO is a very simple plan for you and your employees to administer.
PPO Preferred Provider Plan
What makes a PPO different is its "open access" nature. Open access means that while you stay within a network to receive full coverage, you don't need to choose a PCP. You may go
to any network provider you choose, even a specialist, at any time. A referral for hospital, outpatient or ancillary services is not necessary. You may go outside the network for care,
but your benefits will be slightly lower and the out of pocket cost will be higher. PPO plans normally do not require any submission of claim forms while in-network.
POS Point of Service
A POS has similar features to an HMO, in that your medical care is managed by a primary care physician (PCP). Your PCP becomes your personal physician, the doctor you see for routine
medical care including annual physicals, immunizations and health concerns. Referrals in-network are handled by your PCP and have a small co-payment at the time of service. An additional
benefit in a POS is that you have the ability to self-refer to any physician, but with higher out-of-pocket costs. POS plans normally do not require any submission of claim forms while
in-network.
Traditional
In a Traditional Plan you have complete freedom of provider choice. Services that have been deemed medically necessary are paid out on a variety of cost sharing co-pay and deductible
options. They don't generally cover wellness and routine care, but it can be added in some cases for an additional premium. Traditional plans are the most flexible plan however the
are also the most costly. They normally require submission of claim forms.
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