Most people don’t spend a lot of time trying to understand what the different types of insurances are and what that means to them, most people just want cut and dry “which plan will give me the best coverage for the least money” however I do not believe that this conversation is very cut and dry. Unfortunately there are many different types of plans and their coverage details become more and more convoluted. I want to start with just going over the basics, the 1st thing I learned when being introduced to this world was the different classification that insurance comes in, commercial plans versus government funded programs and now the recent addition being insurance purchased on the exchange usually for a discounted in the form of a tax subsidy. Each of these different branches is very nuanced and requires a bit more examination, today I want to just explore the commercially purchased plans ( these include plans you are getting through your employer). These plans break down into HMO plans and PPO plans.
HMO stands for Health Maintenance Organization
PPO stands for preferred provider Organization
The difference between these two insurances is purely a matter of freedom. When you decide to go with an HMO plan your insurance comes with a set network, which ever doctor you choose and any other doctors or specialist that you may need to see would have to fall within the same network. This network would be called a Medical group usually dictated by the area you are located in. Most medical groups also have separate offices that would require your primary care physician (pcp) or whichever physician is making the request to submit paperwork to them to request an authorization required for most services outside of your standard yearly check up. For most plans you can pick your medical group, usually you are doing it without knowing if your requesting a specific doctor. Choosing a medical group is so important, there is usually more than one in your immediate area and just because your doctor is very organized and on top of your care does not mean your medical group will do the same. The name of the game in this industry is doubt, always make sure your interests are being properly taken care of, do not assume anyone has your best interest at heart, even if they do it is best you stay on top of it as well, there is too much room for error in a situation that can be life or death depending on the issue you are seeking treatment for.
In my line of work there tends to be an assumption that everything will be taken care of between your medical group, insurance and your pcp however there can be a lot of miscommunication, when this happens patients paperwork can sit for a while unauthorized while the medical group waits for more paper or the opposite, an authorization can be issued and sent out to the patient however a provider (supply company) could possibly not get a copy. Most of my patients that get the best care have to take a very active role in their healthcare, so much of what happens can be boiled down to too much work for too few people, companies trying to cut corners to make their profit margins larger.
Usually for an HMO plan depending on the type you get ( I will go into details on coverage in a later post) you will spend less upfront but more later, meaning your monthly cost will not be very much however a lot of times patients will encounter higher deductibles for hospital stays or any “inpatient care”. This is a generalization and there will of course be cases where an HMO plan could be the reverse.
PPOs however are the opposite, the upfront cost , or monthly cost, is usually more however the coverage percentage across the board is usually higher and you no longer have to work within that specific network or “medical group” however the network does not totally go away. Most PPO plans will have an in network coverage rate and an out of network coverage rate, the in network being a higher coverage rate.
There is also a third type of plan that I have neglected to mention, It is called a POS plan or a Point Of Service plan. All this means is that this plan can be used as both, an HMO plan or a PPO plan.
Of course many other shades of grey exist and I want to explore them and explain them, but individually as I feel the complexity can be very over whelming. In my next blog post I will break down the various forms of government funded insurances. I am hoping to fit it all in one post but it is a lot of material and some of it may have to spill into another post. I may have a few mini posts in-between with small healthcare factoids. Thanks for reading and as always
