Healthcare101

Health Insurance

Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care and health system expenses, among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is available to pay for the health care benefits specified in the insurance agreement. The benefit is administered by a central organization such as a government agency, private business, or not-for-profit entity. According to the Health Insurance Association of America, health insurance is defined as “coverage that provides for the payments of benefits as a result of sickness or injury. Includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment”

Plan Types

Participating Provider Network (PPO)

Depending on your specific plan, the PPO works similar to a DHMO while using an In-Network facility. However, it allows you to use an Out-of-Network or Non-Participating Provider. Any difference of fees will become the financial responsibility of the patient unless otherwise specified in your dental policy. As noted, some dental insurance plans may have an annual maximum benefit limit. Thus, once the annual maximum benefit is exhausted any additional treatments may become the patient’s responsibility. Each year that annual maximum is reissued. The reissued date may vary as a calendar year, company fiscal year, or date of enrollment based on your specific plan.

HMO

A health maintenance organization (HMO) is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities in the United States and acts as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO’s guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider’s contracted status.

EPO Insurance

Exclusive provider organization (EPO) plans are managed care systems for people who are in good health and rarely need the services of medical specialists outside their EPO network. In terms of price and access to care, EPOs fall between health maintenance organizations (HMOs) and preferred provider organizations (PPOs). This plan is a managed care system for people who are in good health and rarely need the services of medical specialists outside their EPO network. In terms of price and access to care, EPOs fall between health maintenance organizations (HMOs) and preferred provider organizations (PPOs).

POS Insurance

A point of service plan, or POS plan, is a type of managed care health insurance system. It combines characteristics of the health maintenance organization (HMO) and the preferred provider organization (PPO). The POS is based on a managed care foundation—lower medical costs in exchange for more limited choice. But POS health insurance does differ from other managed care plans. Enrollees in a POS plan are required to choose a primary care physician from within the health care network; this PCP becomes their “point of service”. The PCP may make referrals outside the network, but with lesser compensation offered by the patient’s health insurance company. For medical visits within the health care network, paperwork is usually completed for the patient. If the patient chooses to go outside the network, it is the patient’s responsibility to fill out forms, send bills in for payment, and keep an accurate account of health care receipts.

Supplemental Insurance

Disability insurance – This financial protection plan replaces a portion of your income to assist when if disabled from a covered accident or covered sickness
Accident insurance – Helps cover unexpected medical expenses such as emergency room fees, deductibles and co-payments resulting from fracture, dislocation or other covered accidental injury
Cancer insurance – Helps set the out-of-pocket medical and indirect, non-medical expenses related to cancer that most plans don’t cover.
Critical illness insurance – This plan supplements your major medical coverage by providing a lump-sum benefit you can pay the direct and indirect costs.
Hospital confinement indemnity insurance – This plan provides a set benefit for a covered hospital confinement or a covered outpatient surgery to help and co-payments and deductible.

Dental Insurance

Dental insurance is designed to pay a portion of the costs associated with dental care. There are several different types of individual, family, or group dental insurance plans grouped into three primary categories: (1) Indemnity (generally called: dental insurance) that allows you to see any dentist you want who accepts this type of coverage; (2) Preferred Provide Network dental plans (PPO); and (3) Dental Health Managed Organizations (DHMO) in which you are assigned or select an in-network dentist and/or in-network dental office and use the dental benefits in that network. Generally dental offices have a fee schedule, or a list of prices for the dental services or procedures they offer. Dental insurance companies have similar fee schedules which is generally based on Usual and Customary dental services, an average of fees in your area. The fee schedule is commonly used as the transactional instrument between the insurance company, dental office and/or dentist, and the consumer.

Dental Health Managed Organization (DHMO)

When a dentist signs a contract with a dental insurance company that provider agrees to accept an insurance fee schedule and give their customers a reduced cost for services as an In-Network Provider. Many DHMO insurance plans have little or no waiting periods, no annual maximum benefit limitations, while covering major dental work near the start of the policy period. This plan is sometimes purchased to help defray the high cost of the dental procedures. Some dental insurance plans offer free semi-annual preventative treatment. Fillings, crowns, implants and dentures may have various limitations.

Vision Insurance

Vision insurance is a form of insurance that provides coverage for the services rendered by eye care professionals such as ophthalmologists and optometrists. There are many vision insurance companies. The typical vision insurance plan provides yearly coverage for eye examinations and partial or full coverage eyeglasses, sunglasses, and contact lenses, with or without copays, depending on the plan chosen.

 

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