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Health Insurance should be an easy subject to comprehend. With Studnicky Financials assistance, accessing your benefits and understanding your options will be as familiar as reading the front page of your local newspaper!! The following is a brief overview of the most common individual health plans and the benefit options available today.
Plans:
Health Maintenance Organizations (HMOs)
HMOs are a type of managed care plan. Members of HMOs choose a primary care physician (PCP) who will coordinate their routine care and provide treatment for a variety of medical conditions. In most cases, appointments with specialists must be referred by the primary care physician. In most plans, all but emergency and hospital visits must be pre-approved.
Preferred Provider Organizations (PPO)
Another type of managed care plan is a PPO. This type of healthcare plan offers greater flexibility to choose your doctor or hospital while still controlling your healthcare cost. A PPO allows you the option to self-refer to any provider in the network and still have co pays for most physician services. Hospital and facility fees are usually accessed with a deductible and coinsurance.
Indemnity or Fee-for-Service
An Indemnity or Fee-for-Service plan gives you the most freedom and flexibility. You can choose any doctor, specialist, or hospital you want, and change providers at any time without restriction. The consumer is responsible for the entire deductible, while the coinsurance is a shared fee between both the consumer and the carrier. Since the deductible can range from $100 to $10,000 this plan can fit into any family’s budget.
Benefit Options:
Deductible Options
The deductible is a set amount you are required to pay before the insurance plan begins to pay. For example, if you do not expect many upcoming doctor visits and you only wish to insure for catastrophic situations, you might want to choose a plan with a deductible starting at $1500 or higher. On the other hand, if you have current medical needs, you might want to choose a plan with a lower deductible. The lower the deductible, the more expensive your monthly premium.
Co-pay / Coinsurance
Depending on the health plan you choose, you will pay either a co-pay or coinsurance each time you receive care. The monthly premium is directly related to your co pay selection or coinsurance level. A co-pay is the entire charge a provider receives when a procedure is performed. When selecting a co-pay plan, one needs to remember that as the co-pay is decreased the monthly premium increases. If one can estimate the potential visits to a doctor in a twelve month period it is possible to budget your health care needs.
The coinsurance is a percentage of the total cost of the service a physician or facility provides. The most common plans have a 80/20 coinsurance, where the carrier is responsible for 80% of the cost and the consumer pays the provider 20%. The coinsurance is determined by two methods: fee schedule, reasonable and customary. The fee schedule states the amount one must pay prior to a service while reasonable and customary is a calculation of the providers’ fees in a geographic area for the particular service.
Out-of-pocket costs
The out-of-pocket cost is the total amount of co pays, coinsurance and deductibles each year. HMOs generally have lower out-of-pocket costs than indemnity or PPO plans. Many plans also set a "cap" known as the out-of-pocket maximum. This means that once you reach your maximum, the insurance plan will cover all eligible medical expenses for the remainder of the year. Additional benefits such as prescription drug, dental and vision may not be subject to these out-of-pocket maximums. Prescription coverage
Prescription coverage varies from plan to plan. Some plans are based on a tiered system of co pays, meaning you pay less for generics and more for brand-name drugs. Usually the prescription coverage is subject to a separate deductible and benefit maximum from your core health plan coverage. Individual coverage requires a full medical review and an underwriting process that generally takes 4-6 weeks.
Plan Offerings
Group –We offer multiple plans for groups with 1 – 250 employees
Individual –No matter what your needs, we can provide you with a plan that will fit your budget
Association –We can provide benefits for your members in all 50 states
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