Medical insurance can be very confusing and understanding how insurance works will help you to get the most out of your insurance benefits, and allow you to choose the best plan for you and your family.
HMO (Health Maintenance Organization)
Most individuals choose this type of insurance because it is usually more affordable. Because they are more affordable, you have to give up some freedoms that you may have with a PPO insurance. (see below) Most HMOs work the same way. You have to choose one physician as your primary care physician (PCP). Everything you need must be initiated through your PCP, such as if you need a specialist referral. You also have to choose an IPA (Independent Physician Association). Think of your IPA as which group of specialists that you can see, as well as which facilities you can use for your lab draws, imaging, and which hospital you go to if you need to go to the ER of where you would be hospitalized if necessary.
The advantages of HMO’s are the cost savings. First of all your monthly premium will most likely be lower than a PPO. Secondly, most basic services, such as labs and basic x-rays are usually covered at 100%. In most cases you will have to pay a co-pay at your PCP’s office. I’ve seen them in range from $0-$40. Average co-pay in my office is $15-$20. This is determined by your insurance company and not your PCP. Though you have access to all specialties, you may not have a choice about the specific specialist that you want to see, and a non emergency referral usually takes about 1-2 weeks to get approved.
PPO (Preferred Physician Organization)
This type of insurance gives you more freedom to see which ever physician you choose, provided they are contracted with that insurance company. You also in most cases can directly call a specialist and schedule an appointment without a referral from your PCP. However, this type of insurance will cost you more than an HMO. In general the monthly premiums are higher. Also there are 2 other terms you need to be familiar with, and that is deductible and coinsurance. It is important to find out what your deductible is. With a deductible you owe 100% of the charges from whatever service is rendered from office visits to labs to x-rays/imaging, until you meet that deductible. I’ve seen deductibles range from $0-$5000.00. After you meet your deductible, your insurance will kick in. However, the next thing you need to know is how much is your co-insurance. Average co-insurance is 20%. Meaning the service provided to you is covered at 80%, with the patient responsible for the remaining 20%. Though this type of insurance costs a bit more, you are given much more freedoms. For example, in most cases I as a physician do not need authorization from your insurance company for most referrals.
Medicare/Medicare HMOs
For the purposes of keeping this simple you should assume Medicare works like a PPO. (80% is covered with the patient responsible for the remaining 20%). You can get that 20% covered if you have a secondary insurance such as Medical, or AARP etc.
Medicare HMOs work almost exactly as the HMO described above.
No Insurance/Cash Pay:
A large segment of our population does not have health insurance for various reasons. This does not mean you do not have access to health care. I have a small percentage of my patient population who does not have insurance yet continues to get regular preventative health services. Paying cash for your office visits and labs are probably more affordable than you think. For example I have very reasonable consultation fees, which vary based on whether you are a new or established patient. (new patients are at a higher rate because a complete health history is preformed on the first visit and this requires more time). But also I have deals with certain labs and imaging facilities that give discounts to my cash paying patients. Do not be afraid to get medical attention if you need it and not having insurance is not a valid excuse to allow your health to suffer. Think of it this way. If you do not have health insurance you are not paying a monthly premium. Let’s say for example your monthly premium would have been $400.00/month. This would cost you $4800.00/year. Some people pay this and never use their insurance. So if you have to pay a physician for a consultation once or twice/year, as well as some labs, you are still coming out way ahead and staying healthy. You cannot put a price on your health and defiantly want to avoid an ER visit which can cost you thousands of dollars for one visit. If you do not have insurance please call our office to inquire about our cash rates which are probably more affordable than you think.
Other things to know:
When calling a physicians office especially for the first time please have your insurance card in hand, you will be asked questions about your insurance. It is important that the physicians’ office knows exactly what your insurance is and what benefits is covered so that there are no surprise bills that you may incur. An example of this maybe that some insurance companies cover sick visits only, meaning a general wellness exam such as a physical or pap smear may not be covered. Also, you maybe calling your physicians office to request a referral, again as mentioned above your PCP office would need to know what your insurance is so that they know where to send you.
Insurance can be very confusing, I hope this helps to at least point you in the right direction in both choosing the right insurance for you and your family, as well as understanding how your current insurance works.
Dr. Samawi
