Available Pennsylvania Health Insurance Programs/Options

Available Health Insurance Programs/Options

Fee-for-Service: Fee-for-Service plans often are called traditional or indemnity health insurance. Here, the health insurance company pays all or a portion of the bills after services are received by the insured. Other characteristics of a fee-for-service plan include: 1) no connection between the insurance company and the people who provide health care; 2) no restrictions on the doctors or hospitals you must use to receive health care; 3) a deductible may have to be paid before the policy begins to pay; and 4) co-payments may have to be paid each time you have a claim.

Managed Care: Managed Care plans refer to a variety of health insurance programs such as Health Maintenance Organization (HMO), Preferred Provider Organization (PPO) and Point of Service (POS). These programs vary in provider choice, convenience and costs.

Health Maintenance Organizations (HMOs) are organized systems for health care that provide comprehensive services directly to enrolled members for a fixed, periodic fee. HMOs provide or arrange for health care services through a network or group of health care providers coordinated by the enrollees' primary care physician for such services as routine office visits, diagnostic tests, hospital care, surgical care, emergency care and preventive services. Some HMOs employ the physicians who treat enrolled members at an HMO clinic. Others contract with groups of physicians or individual physicians who maintain their own health center or individual offices where they treat HMO members. Services provided outside the HMO network are not covered except for emergencies or with referrals by the primary care physician and approved by the HMO prior to obtaining services.

Preferred Provider Organization (PPOs) are groups of doctors, hospitals, and other health care providers that have contracts with health insurance companies. The providers agree to serve the company's members and charge negotiated rates. These become the company's preferred providers. Enrollees receive higher levels of coverage (lower deductibles, coinsurance, etc.) when they use preferred providers for medical care.

Point of Service (POS) is a health care plan that allows enrollees to choose whether to receive a specific service from a contracted preferred provider or a non-contracted provider. POS plans are a combination or either an HMO or PPO plan with a traditional indemnity plan. For the maximum level of benefits, the enrollee must consult their primary care physician prior to obtaining treatment or services.