- Usually includes an annual deductible and coverage begins after it has been fully paid. Coverage is sometimes available prior to meeting that deductible for services such as doctor visits (which require a low Co-pay).
- Includes a network of physicians, hospitals, and specialists that have agreed to offer services at a reduced fee.
- No referral from a primary care physician is required to see a specialist.
- Allows the flexibility to visit providers outside the network for a slightly higher fee and a separate deductible.
- Often requires a claim to be filed before your benefit reimbursement can be made.
- Co-pays and monthly premiums are typically higher than that of an HMO plan (see below) due to the flexibility.
- HMO plans usually have co-pays and monthly premiums that are lower than those of a PPO plan.
- There is a network of physicians, hospitals, and other specialists offering services at a reduced fee.
- The patient chooses a primary care physician who helps coordinate the patient’s care. This physician must provide a referral for the patient to see an in-network specialist.
- No coverage for providers outside of the HMO network of physicians, hospitals, and specialists, meaning you’re charged the full fee if you choose to visit them, with the exception of medical emergencies.
- Few or no claims to be filed, since the insurance company pays the provider directly.
As a result of the Affordable Care Act there are different levels of plans with increasingly more benefits and higher costs. These plan levels are: Bronze, Silver, Gold, and Platinum.
There is an additional level for “catastrophic” or very basic plans. To be eligible to purchase these lower-priced plans, you must be under 30 years of age or face financial hardship.
Individuals are able to view and buy health insurance either on the Health Insurance Marketplace (also known as the Exchange) or through an insurance carrier such as Humana. The Marketplace is a website where you can compare different insurance policies from a variety of insurance companies. Depending on your income you may be eligible to purchase a plan at an even lower cost. The open enrollment period for this year will begin Nov. 1, 2015, and runs through Jan 31, 2016, for coverage in 2016. It’s mandatory for individuals to have health insurance, and there are tax penalties for those who don’t enroll.