Plan types

Know what options are available to you.

 

There are essentially three types of health insurance plans: 

 

indemnity plans (fee-for services) 

managed care plans

government sponsored health plans

 

The differences include the choice of providers, out-of-pocket costs and how bills are paid.

There is no one “best” plan for everyone. Some plans are better than others for you, your family, or your employees, but no one plan will pay for all the costs associated with your medical care. 

Govnerment-sponsored
 

Medicaid 

Federal/state public assistance program

created in 1965 for low income individuals.  All states have Medicaid programs.  Eligibility levels and benefits vary.

 

Medicare 

Federal government program

for people 65 and older / those with disabilities.  Pays part of the costs associated with hospitalization, surgery, doctors’ bills, home health and skilled-nursing care.


State Children’s Health Insurance Program  

Administered at the state level

for low-income children not under Medicaid.


Military Health Care 

TRICARE/CHAMPUS 

CHAMPVA 

Department of Veterans Affairs (VA)

 

State-specific Plans 

For low-income uninsured individuals.

Names varyby state.
 

Indian Health Service (IHS)

Department of Health and Human Services program for eligible American Indians.

 

Indemnity plans
 

Cafeteria/Flexible Spending Plans 

Employer-sponsored.  Employees choose benefit package.  Pre-tax conversion plan.


Indemnity Health Plans 

Choose healthcare providers.

Reimbursement for services rendered.

Deductible and copays apply.

Potential restrictions on covered services.

Prior authorization may be required.


“Basic and Essential” Health Plans 

Limited health benefits.  lower cost.

Not ACA-compliant.  Community-rated. Rates may vary considerably.


Health Savings Accounts (HSA) 

Savings product.  Pre-tax contributions pay medical expenses.  Associated with HDHP.  No "use it or lose it" (money stays in account).


High-Deductible Health Plans (HDHP) 

Inexpensive health plan with high deductible.  Benefits begin after deductible is met.

 

Managed Care Options
 

Health Maintenance Organization (HMO) 

Network of participating providers.

Choose primary care doctor from list of network providers.  Primary care doctor coordinates your health care and

refers you to a specialist.  Some HMO's are not "open-access" which means no referral is required to see a specialist.

No out-of-network benefits.


Point-of-Service (POS) 

Indemnity-type plan option.  No referral to see a specialist is required.  Some out-of-network coverage is provided.  Wider network of doctors than HMO network.


Preferred Provider Organization (PPO) 

Charge on a fee-for-service basis.

Providers paid by the insurce company on a negotiated, discounted fee schedule.

Lower costs for in-network healthcare, however some out-of-network coverage is provided.