Understanding Your Health Insurance Benefits

Navigating the world of health insurance can feel overwhelming, especially when you’re trying to determine which type of insurance is best for you and your family.

The two most common types of health insurance plans are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). Both have benefits and limitations. Here’s what you need to know to when selecting the right plan for you.

What Is An HMO?

An HMO (Health Maintenance Organization) is a type of health insurance plan with a specific network of health care providers. This means you will have to stay in-network when seeking care in order for your health care bills to be covered by your plan. 

With an HMO, you will usually need to select a primary care provider (PCP) who will manage your care and give you referrals to see in-network specialists as needed. One exception is that women can receive specialized care from an OB/GYN within the same network as their PCP without needing a referral.

HMOs normally have lower monthly premiums than other insurance plans. They are also less likely to have a deductible you need to meet. Plus, with an HMO you often don’t need to make a copayment when you see an in-network provider.

What is a PPO?

A PPO (Preferred Provider Organization) is a type of health insurance plan that offers more flexibility in choosing health care providers than an HMO. They usually have a larger network of providers than an HMO. Plus, you can see any provider or specialist within the PPO network without needing a referral from your primary care physician.

One thing to note is that PPOs generally have higher monthly premiums than an HMO. Plus, they’re more likely to have copays for provider visits and deductibles to meet before certain benefits are paid. 

HMO or PPO: Which Plan Is Best for You?

When deciding between an HMO or PPO, you want to consider things like the cost, flexibility, and the network of providers.

• Cost: HMOs are generally less expensive than PPOs, with lower monthly payments and fewer out-of-pocket costs. However, both plans may require you to meet a deductible before certain services are covered.
• Flexibility: PPOs offer more flexibility than HMOs, allowing you to see any doctor or hospital in or out of network without a referral. HMOs will typically limit you to a narrower network of providers and you may need a referral from your PCP before you see a specialist.
• Network Size: HMOs generally have a smaller network of providers who have agreed to lower their rates and meet quality standards than PPOs. If you have specific providers you would like to see, you may want to ask them which insurance plans they accept before deciding which insurance plan to enroll in.

Terms You Need to Know

One of the most confusing parts of looking at health insurance plans is understanding all of the specialized words they use. So, we put together this list to help make it easier for you.

Monthly Premium: A health insurance premium is the monthly payment you make to your insurance company to keep your policy active. Premiums are usually billed regardless of whether you use any health care services that month or not. The amount can vary significantly from plan to plan and are often due to be paid near the beginning of each month.

Copay: These are the fixed dollar amounts you will need to make to a medical provider for services, such as a doctor's visit, prescription, or medical test. For example, you might have a $20 copay for a primary care visit and a $30 copay to see a specialist.

Coinsurance: Sometimes under a health insurance plan, you may have coinsurance instead of a copay. This may be the case, for example, for a specialist visit. With coinsurance, you pay a certain percentage of the medical bill, and your insurance pays the rest. For example, if the coinsurance is 80/20, your health insurance pays 80% of medical costs and you pay 20%.

Medicare Coinsurance: If you have Medicare, you will need to pay 20% of a covered service after you meet your deductible. For example, if your coinsurance is 20% and you need an MRI that costs $2,000, you would pay $400 for the MRI and your insurance company would pay the remaining $1,600.

Deductible: This is a set dollar amount a policyholder must pay before their health insurance company begins to cover a portion of their medical expenses. Deductibles can vary by plan and can be as high as $7,050 for individual coverage and more for family coverage. Once the deductible is met, you will usually just make a copy and/or coinsurance for the remainder of the plan year. Plus, most plans also cover in-network preventive care, such as annual physicals and health screenings, at 100% without requiring a deductible. 

Out-of-Pocket Maximum: While the deductible is the amount you need to pay before certain services in your health insurance plan will start, the out-of-pocket maximum is the total amount you may need to pay during the plan year. Once you reach the out-of-pocket maximum, most plans will begin to pay 100% of all covered services until the end of the plan year.

In-Network vs. Out-of-Network: In-network health care providers have a contract with the health insurance plan to accept negotiated rates for services, while out-of-network providers do not. This means that patients typically pay less for in-network services and more for out-of-network services.

Prior Authorizations: Prior authorization in health care is a requirement that a health care provider, such as your primary care physician or a hospital, must get approval from your insurance plan before prescribing you medication or doing a specific medical procedure. Your medical provider will usually take the lead on submitting a prior authorization request and communicating with the health plan to increase your chances of being approved. 

Innovista Medical Center Is Here to Help

Innovista accepts Medicare, as well as all Blue Cross and Blue Shield of Texas health insurance plans. If you have any questions about your health insurance plan or your coverage, just call us at 866-324-0301. We’re here as your medical partners to help keep you and your family healthy.