The richer the benefits and the more freedom you want, the more a plan will cost.

Buying the lowest cost health plan from a health insurer may not be a wise decision.  Choose a health insurance company that has shown a lot of stability, that is a well known company and is a major provider of health insurance in the State.

Health Plan Basics

How is your health insurance being managed?
When you have a PPO or an HMO Plan, you have a managed care plan.  There is an agreement or contract between the insurance company and the doctor, hospital, or other health care provider that belongs to the provider network.  In an HMO, the connection can be very strong, such as having the physicians be salaried employees of the HMO.

In the other cases, the physicians are under contract and agree to be compensated on a capitated rate basis.  In a PPO and Open Access HMO, doctors agree to provide their services to the plan’s members at a lower price in exchange for that health plan encouraging it’s members to use those doctors.  The doctors like it because they get more patients, and the health plan likes it because it saves money.  Consumers like it because it costs less and the benefits are richer.

The different types of managed health care plans. 

PPO (Preferred Provider Organization)
PPO’s offer cost-sharing incentives to encourage members to use a network of participating providers with whom the plan negotiates discounted rates.  The networks are usually very large, and the members are free to seek care from any physician or provider within the network or outside the network.  Obviously, the member gets better coverage if he or she uses physicians and hospitals within the network.  These benefits come in the form of front-end copayments and lower coinsurance.  Typically PPO’s will offer front-end copayments for such services as doctor visits, lab tests, x-rays, and prescriptions.  These front-end copayments are usually not subject to your calendar year deductible, and are usually only available in-network.  Most other covered services (i.e., inpatient hospital services and surgeries) are typically subject to your calendar year deductible and co-insurance.

Deductible choices can range from $250 up to as high as $5,000.  Coinsurance is a percentage (80/20) of the remaining covered services that you will pay after your deductible up to specified limit – once that is met, then the insurance company will pay 100% for the rest of the calendar year.  PPO’s do not generally offer maternity coverage.

HMO (Health Maintenance Organization)
An HMO provides very rich benefits – often extensive preventive care coverage and low out-of-pocket costs – but only if you go to a medical provider associated with the HMO.  Except in an emergency, there is typically no coverage for care from doctors and hospitals outside your HMO.  Plans usually offer comprehensive health care benefits and affordable premiums with no deductibles and minimal cost-sharing (such as low copayments for doctor visits and other services).

Primary Care Physicians, often referred to as “Gatekeepers”, oversee all your care and coordinate referrals to specialists when necessary.  HMO’s are your only choice for comprehensive maternity coverage.