Different Types of Oregon Health Insurance

Types Of Health Insurance

Understanding the different types of insurance -- their costs, what they cover and their rules -- is important. It will help you to compare plans if you are shopping or to make the best use of your plan if you are already covered. For example:

• Some insurance plans require you to use their providers and hospitals. Health Maintenance Organizations (HMOs) are examples. Kaiser Permanente probably is the best-known HMO. Patients go to Kaiser facilities and see Kaiser doctors at those facilities. However, other insurance companies also offer plans that require you to use certain providers if you want claims covered. In these cases, the company contracts with doctors in the community. Instead of being called an HMO, might be called an Exclusive Provider Organization (EPO).
• Other plans cover you if you use doctors that are not part of your health plan's "network" but you pay a greater percent of the costs. One example is a Preferred Provider Organization (PPO). Many health insurance companies offer PPOs and this is the most common type of plan offered by employers.
• There are still some "traditional" (also called indemnity or fee-for-service) plans although they enroll fewer and fewer people. These plans allow you to see any provider you want without financial penalty and without referrals to specialists. The price for this freedom? Your total medical costs typically are higher than with the managed care plans described above.

Below are some of the terms used to describe health plans and their features. An insurance agent or insurance company can help you understand the type of plan that is best for you. Once you read about the types of plans, there are some common questions you can use to compare health plans.

Preferred Provider Organizations/Point-of-Service Plans

• Your costs will be less if you use a doctor or specialist who is part of the plan but you can get some coverage for other doctors. Providers that are part of the plan are called "in-network" or "preferred."
• Premiums tend to be higher than for HMOs.
• POS plans have primary care physicians who coordinate patient care. PPOs generally do not.
• If you use a provider who is not in the network, you may have to meet a separate and higher deductible before your plan begins to pay benefits. You may have to pay the entire bill yourself and submit paperwork to your plan to get reimbursed.
• You generally don't have to submit claims to the insurance company when you use in-network providers.
• You may have a co-pay for some visits. For some services, you may have a deductible and coinsurance (a percent of the bill that is yours).
• If you are in a PPO, you may not need a referral to see a specialist but you may need to take paperwork. Ask your doctor about this.

Health Maintenance Organizations (HMOs) such as Kaiser Permanente

• You must use the plan's doctors/hospitals, unless you are referred out-of-network by your primary care physician. This includes specialists.
• Your total medical costs will likely be lower and more predictable than with a fee-for-service plan.
• Traditionally, you have co-payments rather than deductibles and co-insurance (percentage amount). However, this is changing. Many HMOs now have deductibles. A co-pay might be $10 to $20 for an office visit.
• There generally is no lifetime limit on coverage.
• A primary care physician coordinates your care. This might be family practice doctor, internist, pediatrician, obstetrician-gynecologist, or general practitioner.
• Your primary care doctor must refer you to a specialist.
• You may need prior approval for non-emergency hospitalization.
• Generally, you won't have to fill out insurance forms or submit claims to the insurance company.

Indemnity Insurance (also called fee-for-service)

• Typically, you may choose any doctor you wish and you may change doctors at any time.
• You probably won't need a referral to see a specialist or go for X-rays or tests but may need medical records or other paperwork from your primary care physician.
• Typically, you have a deductible, a dollar amount you spend each year on health care before your plan starts to contribute. Once the deductible is met, the insurance company then pays a part of the bill - typically 80 percent. You pay the other 20 percent. This is coinsurance.
• You may have more paperwork. Some doctors will send the claim to the insurance company for you, and then bill you for the difference after the insurance company pays them. With other doctors, you will have to pay the entire bill and file a claim with your insurance company to be reimbursed.
• You will have a "cap" that limits how much you'll have to pay in medical bills each calendar year. This is may be referred to as maximum coinsurance or your out-of-pocket maximum. Once your medical bills reach this amount, the plan typically pays 100 percent for covered services for the rest of the calendar year.
• If your doctor bills you more than the reasonable and customary charge, you may be responsible for the excess. This is called balance billing. Ask your plan about this.
• You may have a lifetime limits on benefits paid. Most experts recommend a lifetime limit of at least $1 million.

Prescription Drug Coverage

The health plan you select will likely include prescription drug coverage. Typical features include:

• A "formulary," or list of drugs that the plan covers.
• Co-pays based on whether you buy a generic drug, a brand-name formulary drug, or a brand-name drug not on the plan's formulary. For example, the co-pay might be $15 for a generic drug, $30 for a formulary drug, and $50 for a brand name, non-formulary drug.
• Mail-order pharmacy option: You send your doctor's prescription for routine maintenance drugs (for example, blood pressure medicine) to the mail-order pharmacy. In most cases, you receive a three-month supply of your medication by return mail. You still pay a co-pay, but your cost may be lower than at a local, retail pharmacy. Some employer plans require use of mail-order pharmacy.

Other Health Insurance Options and Plans

There are other types of insurance, some of them coupled with tax benefits, designed to fit particular needs. And, there are products such as discount medical plans that are not insurance.

Make sure you understand what you are buying. Learn more about:

• Federal Tax Advantaged Options
• Short-term Policies
• Supplemental (or limited-benefit) Plans
• Discount Medical Plans