Health Insurance Fresno

Individual and family health insurance is a type of health insurance coverage that is made available to individuals and families, rather than to employer groups or organizations. Given the option, most people would prefer to have their employer provide group health insurance coverage. But, if this is not an option for you, it is still important for you to seek coverage. You may be pleasantly surprised with the variety and affordability of the individual and family health insurance options available.

Below is a list of the major categories of health insurance available to you with definition for some common terms.

Preferred Provider Organizations (PPO)

A Preferred Provider Organization (PPO) is an alternative type of health plan that has quickly become the most commonly recognized and available type of plan offered by insurance companies. A PPO plan has similarities to both an HMO and indemnity plan. Similar to an HMO plan, there is a specific group of doctors and hospitals selected by the insurance provider, referred to as "preferred providers," because these doctors and hospitals have contracted with your insurance company to provide services to their plan members at predetermined and discounted rates.

Also like an HMO plan, there is no claim form that must be submitted by the insured member. When you receive services from a preferred provider, all claims are handled between that health care provider and the insurance carrier. However, unlike and HMO plan, you can choose to visit any physician within their network of doctors and do not need to select a primary care physician. This greater freedom of choice more closely resembles that provided under an indemnity plan. Many PPO plans provide you with the ability to visit any doctor or hospital that you wish, just as you can under an indemnity plan, and typically there is no limit to the geographical area within the state. However, if you choose to visit a physician or medical facility that is not part of the PPO's list of preferred providers, you will be required to pay a higher coinsurance percentage and may need to file you own claim form to receive reimbursement from the insurance company. Accessing a non-participating physician is referred to as going "out-of-network" and many PPO plans will place greater limitations and lower maximum benefit levels for this expanded availability.

When you enroll in a PPO plan, you will be asked to select your plan deductible and coinsurance limit. Many companies that offer PPO plans will have a unique name or brand for the different levels of PPO plans that they offer. Some have low deductible with high coinsurance percentages, while others may have high deductibles with lower coinsurance percentages. Just about every possible combination of coverage limits you could imagine is available from most insurance carriers offering this type of health plan. In many cases, you can customize a PPO plan to best meet your budget and your medical care expectations. Once you are enrolled in a PPO plan, it works similar to an indemnity plan. You must first meet your annual deductible (when applicable) and then you will pay your coinsurance percentage for covered benefits for the remainder of the calendar year. All PPO plans provide a maximum annual co-insurance maximum, which tells you what the maximum is that you could possibly pay for covered services during the year. This is also commonly known as the annual "out-of-pocket" maximum. Not all covered services may apply to this maximum, and "out-of-network" services may have a separate maximum. Always refer to the plan details of any PPO closely for the details on coverage limits and maximums.

Health Maintenance Organizations (HMO)

This type of health plan provides the most comprehensive level of coverage with the lowest share of cost passed on to the insured. Health Maintenance Organizations (HMO) are considered "pre-paid," meaning that you pay for your health care in advance in the form of a monthly premium. There may be small co-payments required for some covered services, such as office visits and prescription drugs, which must be paid to the health care provider at the time service is provided. The monthly fees remain the same, regardless of types or levels of services provided and doctor's visits are the same co-payment regardless of most of the medical treatments provided. Greater varieties of HMO plans are appearing, many of which require an annual deductible be met for some covered services, as a result of rising health care costs. The HMO plan with a $10 office visit and 100% hospital services still exist, but it is becoming scarce in relation to HMO plans that require higher co-payments and deductibles.

Any medical treatment under an HMO plan must be received within the network of physicians that is operate by the insurance carrier, or from a medical group that has a contract to provide health care for that insurance company. These medical professionals are paid a monthly capitation fee by the insurance company for accepting new members under the HMO plan and must provide you with the required care that is outlined in your HMO plan contract. Except for some medical expenses, such as emergency medical treatment, services you receive outside of this specified network of physicians and medical facilities will not be covered. With an HMO plan, you choose a primary care physician that oversees all of your health care needs and make any necessary referrals to specialists within his medical group.

Since these physicians that are under contract with the insurance company receive a fixed monthly capitation fee from the insurance company, it is in their best interest to keep your health care costs down. The health care costs and repeat regular visits from plan members are absorbed by the physician or his medical group, even if the cost of treatment exceeds his compensation from the insurance company. For these reason, many HMO plans focus on preventive health care and regular screenings in order to catch a treat an illness quickly. It is important to understand the limitations of your HMO plan on what medical expenses are not covered. There may be exclusions or limitations on such things as chiropractic care, mental health disorders and maternity coverage. It is also important to select a primary care physician with whom you are comfortable in allowing him to make decisions regarding your health.

Point-Of-Service Plans (POS)

The Point-of-Service (POS) plan is considered the "Cadillac" of health plans and is by far the most expensive of all the types of health insurance. Due to the rising costs of health insurance, many companies have stopped offering POS plans because the number of people enrolling in this type of coverage was decreasing steadily. A POS plan combines the best parts of the other types of health insurance and provides three levels of health care to choose form. It combines access to comprehensive coverage and low co-payments and coinsurance through the HMO side of the plan. At the same time, it provides access to the preferred provider network through the PPO side of the plan, and even gives access to out-of-network providers.

With a POS plan, you are required to select a primary care physician, just as you do with an HMO plan. However, you are not obligated to use the services of this primary care physician. The incentive to seek treatment first from your primary care physician is that your coverage will be more comprehensive if you go through the HMO network of your primary doctor. Also, your out-of-pocket expenses will be lower because usually there is no deductible associated with treatment received through the HMO network.

The second level of coverage under a POS plan is through the PPO network. This benefit works just like a separate PPO plan would work, and you may have to meet an annual deductible and pay a coinsurance for most covered services. Some POS plans offer set office visit co-payments when using a PPO provider, but these are typically higher than those available through the primary care physician. Under the PPO network, you may self-refer to specialists and claims will be handled by the physician or medical group on your behalf.

The third level of benefits under a POS is the access to "out-of-network" providers. Like an indemnity plan, you have the freedom under this level to go to any physician or hospital anywhere in the country. Your out-of-pocket costs will be considerably higher if you seek medical treatment under this level of the POS plan. The deductible and coinsurance are higher than the PPO level, and you may also be responsible for filing your own claims for reimbursement.

The primary purpose for choosing a POS plan is to have the comprehensive coverage through the HMO network of your primary care physician, while also having the freedom to use any health care professional of your choosing. Therefore, it is important to make sure that the HMO network has physicians and hospitals that are conveniently located to your home or place of work. If the network is limited, or non-existent, paying the extra premium for a POS plan would not make sense. For the same reason, you will also want to make certain the PPO network also utilizes the majority of doctors and health care facilities in your area. Although a POS plan may seem like the ideal health care coverage, the monthly premium may not make financial sense.

Health Savings Accounts (HSA)

An HSA health plan is a health insurance policy that meets the guidelines for qualifying for a Health Savings Accounts (HSA). An HSA is an account to which individuals, family members and employers can make tax-deductible cash contributions, similar to an IRA. These funds can then be used to reimburse the individual (tax-free) for qualifying medical expenses such as deductibles, co-payments, dental and vision care. Withdrawals from the account are exclusively for the purpose of paying qualified medical expenses of the account beneficiary.

HSA accounts, and the tax laws that accompany them, were established by the Medicare Prescription Drug Improvement and Modernization Act of 2003. In order to open and HSA, you must first been enrolled in a health plan that meets the federal guidelines. If you purchase and HSA qualified health plan, you are not required to open, or make deposits, into an HSA account.

Money that you contribute to a Health Savings Account belongs to your (the depositor) or the beneficiary on the account and you have access to the money at any time. There are penalties for early withdrawal if the money is not used for eligible health care expenses. You can make an additional deposit into this account every year and if you are insured under an HSA plan through your employer, the employer is permitted to make the annual contribution and they will receive the tax-deduction benefit. If your employer has a "cafeteria plans" you can make indirect deposits into your HSA through a salary reduction plan.

Many insurance companies offer health plans that meet HSA eligibility, and they are become more common as the cost of health insurance rises nationwide. These are high deductible health plans (HDHP) that have a set deductible amount, ranging from $1,050 to $5,250 for individuals. The availability of deductible options depends on your state of residence and the access to insurance companies offering this type of coverage. The annual out-pocket-maximum (coinsurance limit), must also not exceed a specific dollar amount in order to qualify as and HSA health plan. This limit may be low compared to the maximum limit on many PPO plans. Once this maximum has been met, the insured member is covered in full for the remainder of the calendar year for all medical expenses covered under the plan. One unique feature of an HSA plan is that prescription drug coverage is treated like any other covered medical expense. You must first meet the annual deductible, and then a set coinsurance until you reach the maximum.

An HDHP plan will often work with a network or preferred providers, much like a PPO plan. Using this network for health care will provide you access to services at lower negotiated rates. However, you will have the freedom to use physicians outside of the network, but at a higher share of cost to you, at rates that are not monitored by your insurance company. Some HDHP plans may place emphasis on preventive health care by allowing you annual physical exams and well-care checkups without having to meet your deductible first. The availability of this benefit varies from one insurance company to another and may not be available in all states.

Wondering about some of the terms used in health insurance?

Here are some common terms and definitions.

Pre-existing condition: An illness, disease or condition an individual has at the time of enrollment in a health care plan. Pregnancy is not a pre-existing condition.

Catastrophic coverage: This plan pays hospital and medical expenses above a certain (usually high) deductible. The maximum lifetime limit may be high enough to cover the cost of a catastrophic illness.

Long-term care policies: These cover medical care, nursing care and certain in-home care if you ever become unable to care for yourself due to an extended illness or disability.

Disability income insurance: This plan will provide you with an income if you become unable to work due to an injury or illness. Benefits are usually 60% of your income at the time of disability.

Premium: The amount the policy-holder pays to the health plan each month to purchase health coverage.

Deductible: The amount that the policy-holder must pay out-of-pocket before the health plan pays its share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health plan. It may take several doctor's visits or prescription refills before the policy-holder reaches the deductible and the health plan starts to pay for care.

Copayment: The amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service. For example, a policy-holder might pay a $45 copayment for a doctor's visit, or to obtain a prescription. A copayment must be paid each time a particular service is obtained.

Coinsurance: Instead of paying a fixed amount up front (a copayment), the policy-holder must pay a percentage of the total cost. For example, the member might have to pay 20% of the cost of a surgery, while the health plan pays the other 80%. Because there is no upper limit on coinsurance, the policy-holder can end up owing very little, or a significant amount, depending on the actual costs of the services they obtain.

Exclusions: Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket.

Coverage limits: Some health plans only pay for health care up to a certain dollar amount. The policy-holder may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some plans have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum, and the policy-holder must pay all remaining costs.

Out-of-pocket maximums: Similar to coverage limits, except that in this case, the member's payment obligation ends when they reach the out-of-pocket maximum, and the health plan pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year.