Health Insurance Basics

Types of Health Plans

There are four plan types that offer a variety of options in terms of benefits, approaches to providing care, and cost:

• Indemnity (also called “fee-for-service”) plans provide members total freedom to determine which hospitals or doctors they use for their care.

• Preferred Provider Organization (PPO) plans provide members with greater levels of coverage for choosing health care providers from a network of “preferred providers”.

  PPO plans typically have copayments or coinsurance amounts that a member pays when services are used, such as a doctor’s appointment. These amounts are usually lower when services are received from a PPO provider.

• Primary Care Model plans require members to select a primary care provider (PCP) from a specific provider network. The PCP provides and coordinates all the member’s care. If the member needs to see a specialist or receive other treatment, it is the PCP’s responsibility to secure the appropriate approval from the insurance company for these services.

  Members are responsible for copayment or coinsurance amounts for services when they see network providers. Members who go to providers outside the network for care (without receiving prior authorization from the plan) must pay the entire cost.

• Point-of-Service (POS) plans require members to select a PCP from a specific network. Members can receive care outside of the network, but out-of-pocket expenses will be higher.
  
  
• Open Access plans allow members to see any provider in the specified network. A referral from the PCP is not necessary. Benefits are not available for services received outside of the the network.

Note: These are general descriptions. Your health plan may vary.