Health care in America is changing rapidly. Twenty–five years ago, most people in the United States had indemnity insurance coverage. A person with indemnity insurance could go to any doctor, hospital, or other provider (which would bill for each service given), and the insurance and the patient would each pay part of the bill.
But today, more than half of all Americans who have health insurance are enrolled in some kind of managed care plan, an organized way of both providing services and paying for them. Different types of managed care plans work differently and include preferred provider organizations (PPOs), health maintenance organizations (HMOs), and point–of–service (POS) plans.
You’ve probably heard these terms before. But what do they mean, and what are the differences between them? And what do these differences mean to you?
What Are My Health Plan Choices?
Choosing between health plans is not as easy as it once was. Although there is no one “best” plan, there are some plans that will be better than others for you and your family’s health needs. Plans differ, both in how much you have to pay and how easy it is to get the services you need. Although no plan will pay for all the costs associated with your medical care, some plans will cover more than others. Almost all plans today have ways to reduce unnecessary use of health care–and keep down the costs of health care, too. This may affect how easily you get the care you want, but should not affect how easily you get the care you need.
Plans change from year to year, so you should carefully consider each plan, using the questions outlined in this booklet. If you get health insurance where you work, you should start with your employee benefits office. Its staff should be able to tell you what is covered under the plans available. You can also call plans directly to ask questions.
Health insurance plans are usually described as either indemnity (fee–for–service) or managed care. These types of plans differ in important ways that are described below. With any health plan, however, there is a basic premium, which is how much you or your employer pay, usually monthly, to buy health insurance coverage. In addition, there are often other payments you must make, which will vary by plan. In considering any plan, you should try to figure out its total cost to you and your family, especially if someone in the family has a chronic or serious health condition.
Indemnity and managed care plans differ in their basic approach. Put broadly, the major differences concern choice of providers, out–of–pocket costs for covered services, and how bills are paid. Usually, indemnity plans offer more choice of doctors (including specialists, such as cardiologists and surgeons), hospitals, and other health care providers than managed care plans. Indemnity plans pay their share of the costs of a service only after they receive a bill.
Managed care plans have agreements with certain doctors, hospitals, and health care providers to give a range of services to plan members at reduced cost. In general, you will have less paperwork and lower out–of–pocket costs if you select a managed care type plan and a broader choice of health care providers if you select an indemnity–type plan.
Over time, the distinctions between these kinds of plans have begun to blur as health plans compete for your business. Some indemnity plans offer managed care–type options, and some managed care plans offer members the opportunity to use providers who are “outside” the plan. This makes it even more important for you to understand how your health plan works.
Besides indemnity plans, there are basically three types of managed care plans: PPOs, HMOs, and POS plans.