Health Insurance: Understanding the Basics

Americans today receive a barrage of health insurance information from every direction. Pundits speak of the national health care crisis; Medicare now offers additional options; and employee benefits officers often speak in a jumble of letters from HMO to PPO. For the consumer, choosing a health insurance plan can be quite confusing.

Health insurance is not "one size fits all." Depending on your current state of health, budget, and individual needs, the best insurance for you may be far different than the best insurance for your friend or family member. A basic understanding of the various types of insurance that are available, and what each does and does not cover, can be helpful in determining which plan will work best for each person.

Traditional health insurance, also called "fee for service" or 80/20, is the type of insurance that most of us grew up with. You are entitled to visit any doctor, and the insurance company pays 80% of the bill. This type of insurance offers the greatest flexibility, but carries the highest out of pocket expenses. A deductible must be met before the insurance company will pay. The lower your monthly premium, the higher the deductible will be. The insurance company usually reserves the right to cap payments if, in their opinion, the doctor's fees are higher than what is "reasonable and customary" in your area. This is an excellent type of coverage to have if you become extremely ill and require a network of specialists, or if your medical bills are astronomical. Once your expenses for the year reach a certain level, the insurance company will take over and pay 100%.

Many healthy people do not need fee for service medical insurance. They find that their out of pocket expenses are much lower with a "managed care" plan. There are two basic types of managed care - HMO and PPO.

In an HMO, or Health Maintenance Organization, you pay a monthly premium in exchange for comprehensive medical care. There is usually a small co-payment for doctor's visits (usually ranging from $5 to $25), and a somewhat higher co-pay or deductible for hospitalization. Your out of pocket expenses are significantly easier to predict and manage with an HMO rather than a fee for service plan. However, an HMO introduces the concept of a "gatekeeper." In an HMO, you must choose a primary care physician. That doctor, working in tandem with a risk management insurance officer, will determine your access to specialists. Finally, an HMO requires you to use doctors that are part of the HMO's network. If you travel a lot, be sure to find out what the provisions are should you require an out of network doctor.

A PPO, or Preferred Provider Organization, can be considered a blend of HMO and fee for service plans. You will choose a primary care physician, and generally use doctors that are part of the organization. However, a PPO lets you see doctors who are not part of the network for a somewhat higher fee. This increased flexibility is excellent for those who travel frequently, or for those whose current doctor is not a member of the organization.

Many other options exist for covering your medical expenses. A Health Savings Account allows you to set aside pre-tax dollars each month. Catastrophic insurance carries a low premium with a high deductible, and is designed to cover you if you develop a serious illness or injury. However, for the average consumer, the choice is generally between fee for service and managed care. All types of plans carry their own advantages and disadvantages, and it is important to understand what these are in order to make the right decisions for your family.