Plan Types

types of plans

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Different types of plans help you get and pay for care differently.

fee-for-service (ffs) plans generally use two approaches.

fee-for-service (ffs) plans (not ppo)

A type of traditional insurance in which the health plan will pay the medical provider directly or reimburse you after you have filed an insurance claim for each covered medical expense. when you need medical attention, visit the doctor or hospital of your choice. this approach may cost you more and require additional paperwork.

Reading: What does ffs stand for in health insurance

fee-for-service (ffs) plans with a preferred provider organization (ppo)

an ffs option that allows you to see medical providers who reduce your charges to the plan; You pay less money out of pocket when you use a ppo provider. When you visit a PPO, you usually won’t have to file any claims or paperwork. however, going to a ppo hospital does not guarantee ppo benefits for all services received within that hospital. For example, laboratory work and radiology services from independent physicians within the hospital may not be covered under the PPO agreement. most networks are fairly large, but they may not have all the doctors or hospitals you want. this approach will usually save you money.

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Enrolling in an ffs plan generally does not guarantee that a ppo will be available in your area. PPOs have a stronger presence in some regions than others, and in areas where there are regional PPOs, the non-PPO benefit is the standard benefit. in “ppo only” options, you must use ppo providers to get benefits.

health maintenance organization (hmo)

a health plan that provides care through a network of doctors and hospitals in particular geographic or service areas. hmos coordinates the health care service you receive and frees you from filling out paperwork or being billed for covered services. your eligibility to join an hmo is determined by where you live or, for some plans, where you work. Some hmos are affiliated with or have arrangements with hmos in other service areas for non-emergency care if you travel or are away from home for extended periods of time. plans that offer reciprocity discuss this in their brochure. hmos limits your out-of-pocket costs to the relatively low amounts shown in the benefit booklets.

  • The hmo provides a full set of services, as long as you use the hmo’s affiliated doctors and hospitals. hmos charge a copay for primary care doctor and specialist visits and generally have no deductible or coinsurance for hospital care.
  • Most hmos ask you to choose a doctor or medical group to be your primary care physician (pcp). your pcp gives you general health care. In many hmos, you must get authorization or a “referral” from your pcp to see other providers. a referral is a recommendation from your doctor that you be evaluated and/or treated by a different doctor or medical professional. Referral ensures that you see the right provider for the most appropriate care for your condition.
  • care received from a provider who is not in the plan’s network is not covered unless it is emergency care or the plan has a reciprocity agreement.
  • hmo plans that offer a point of service (pos) product

    In an hmo, the pos product allows you to use providers that are not part of the hmo network. however, you pay more to use these out-of-network providers. You generally pay higher deductibles and coinsurance than you pay with a plan provider. You will also need to file a claim for reimbursement, such as in an FFS plan. The hmo plan wants you to use its provider network, but recognizes that members sometimes want to choose their own provider.

    some plans are point of service (pos) plans and have similar features to ffs and hmos plans.

    consumer driven health plans (cdhp)

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    describes a wide range of approaches to give you more incentive to control the cost of your health benefits or medical care. You have greater freedom to spend health care dollars up to a designated amount, and you receive full coverage for in-network preventive care. in return, you bear significantly higher cost-sharing expenses after you have exhausted the designated amount. the catastrophic limit is usually higher than usual in other plans.

    high deductible health plan (hdhp)

    A high deductible health plan is a health insurance plan in which the member pays a deductible of at least $1,250 (self-only coverage) or $2,500 (family coverage). the annual out-of-pocket amount (including deductibles and copays) paid by the member cannot exceed $6,350 (self-only coverage) or $12,700 (family coverage). these dollar amounts are for 2014. hdhps may have first-dollar coverage (no deductible) for preventive care and higher out-of-pocket copays and coinsurance for services received from out-of-network providers. The HDHPs offered by the FEHB program establish and partially fund HSAS for all eligible members and provide a comparable HRA for members who are not eligible for an HSA. HSA premium funding or HRA credit amounts vary by plan. For more information, check out our fast facts on hdhp.

    health reimbursement arrangement (hra)

    Health reimbursement arrangements are a common feature of consumer-oriented health plans. the health plan may refer to them by a different name, such as personal care account. They are also available to those enrolled in high deductible health plans who are not eligible for an HSA. HRAS are similar to HSAS, except that a member cannot make deposits in an HRA, a health plan may cap the value of an HRA, no interest is earned on an HRA, and an HRA amount is not transferable. if the member leaves the health plan.

    health savings account (hsa)

    A health savings account allows individuals to pay for current health expenses and save for future qualified medical expenses on a pre-tax basis. funds deposited into an hsa are not taxed, the hsa balance grows tax-free, and that amount is available tax-free to pay for medical costs. To open an HSA, you must be covered by a high deductible health plan and cannot be eligible for Medicare or covered by a plan other than a high deductible health plan or general purpose HCFSA or rely on the statement someone else’s tax. hsas are subject to a series of rules and limitations established by the treasury department. visit the treasury resource center for more information.

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