What Health Insurance Options are Available in the US

Picking the right health insurance plan in the US can seem like a daunting task. There are so many options, and the last thing you want is to be unprepared if something happens. To help with some of these options, The Medicare Store will walk you step by step to what coverage is right for you. In this post, however, we’ll look at a basic overview.

Managed Care Explained

You’ll hear this term a lot in health care as “managed care” is how health insurers control costs. Almost all health plans have this program, as managed care determines how much health care you can use. For example, if you go to the hospital without being approved, you might have to cover your hospital bill.

Fee-For-Service Health Plans

With fee-for-service health care plans, the insurer only pays a part of your hospital and doctor bills. You will pay a monthly fee called a premium. You would pay a deductible, which is a feed you need to pay before your health insurance begins. Once paid, your insurer will pay a part, usually a larger part, of your hospital or doctors bill. For example, they’ll pay 80%, and you’ll pay 20%, with your portion being called “coinsurance.”

Most fee-for-service plans have a “cap,” and you reach this cap when your out-of-pocket insurance totals to a certain amount. Check with your health coverage to see what’s included before making a claim to your health insurance company.

There are two options for fee-for-service health coverage: basic and major medical.

  • Basic: Pays towards the costs of a room in a hospital and health care while you’re at the hospital. Some hospital services and supplies, such as x-rays and prescribed medicine, is also covered. Basic coverage will pay towards surgery cost, whether it’s performed in or out of hospital.
  • Major Medical: Takes over where your basic coverage stops. Covers long, high-cost illnesses or injuries.

Some companies combine basic and major medical, and others do not so make sure to do your research.

HMO: Health Maintenance Organizations

An HMO is a prepaid health plan where you pay a monthly premium. In exchange, the HMO will provide comprehensive health care for you and your family, including hospital stays, emergency care, doctors’ visits, lab tests, x-rays, surgery, and therapy. Your doctors are usually limited to those who have agreements with an HMO, but exceptions are made in emergencies.

HMOs will typically provide preventative care. Keep in mind that you’ll usually have to wait longer than those who are under a fee-for-service plan. In almost all HMO plans you’re assigned a doctor, and you often can’t see a specialist unless this doctor makes a referral. Research the care given by specific HMO’s before signing up with one.

POS: Point-of-Service Plans

Many HMOs will offer an indemnity-type option, such as a POS plan. These allow you to refer yourself to another service while still being able to get some coverage. However, if a doctor makes that referral, the health care plan will cover all or most of the bill.

PPO: Preferred Provider Organizations

A PPO is a combination of fee-for-service and an HMO. When you go to a doctor within the PPO, you present your card to the office and you do not need to fill out a form. A small co-payment is typically paid at each visit. For some health care services, you may need to pay a deductible and coinsurance. PPOs also require you to choose a primary doctor for your health care. Most PPOs cover preventive care, which includes doctor visits, well-baby care, immunizations, and mammograms. In this plan, you can go to doctors not in your plan, and still receive some coverage.