Several types of Medical Insurance are available depending on state and/or federal regulations and how you want to classify them. Fee-for-Service (sometimes called Indemnity Plan). You can use any medical provider (such as a doctor and hospital). You or they send the bill to the insurance company, which pays part of it. Usually, you have a deductible�such as $200�to pay each year before the insurer starts paying. Once you meet the deductible, most indemnity plans pay a percentage of what they consider the "Usual and Customary" charge for covered services. The insurer generally pays 80 percent of the Usual and Customary costs and you pay the other 20 percent, which is known as coinsurance. If the provider charges more than the Usual and Customary rates, you will have to pay both the coinsurance and the difference. The plan will pay for charges for medical tests and prescriptions as well as from doctors and hospitals. It may not pay for some preventive care, like checkups. Managed Care . Most Americans have some kind of managed-care plan. Various plans work differently and can include: health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans. Managed care plans provide comprehensive health services to their members and they offer financial incentives to patients who use the providers in the plan. Preferred Provider Organization (PPO). A PPO is a form of managed care closest to an indemnity plan. A PPO has arrangements with doctors, hospitals, and other providers of care who have agreed to accept lower fees from the insurer for their services. As a result, your cost sharing should be lower than if you go outside the network. In addition to the PPO doctors making referrals, plan members can refer themselves to other doctors, including ones outside the plan. If you go to a doctor within the PPO network, you will pay a copayment (a set amount you pay for certain services�say $10 for a doctor or $5 for a prescription). Your coinsurance will be based on lower charges for PPO members. If you choose to go outside the network, you will have to meet the deductible and pay coinsurance based on higher charges. In addition, you may have to pay the difference between what the provider charges and what the plan will pay. Health Maintenance Organization (HMO). HMOs are the oldest form of managed care plan. HMOs offer members a range of health benefits, including preventive care, for a set monthly fee. There are many kinds of HMOs. If doctors are employees of the health plan and you visit them at central medical offices or clinics, it is a staff or group model HMO. Other HMOs contract with physician groups or individual doctors who have private offices. These are called individual practice associations (IPAs) or networks. HMOs will give you a list of doctors from which to choose a primary care doctor. This doctor coordinates your care, which means that generally you must contact him or her to be referred to a specialist. With some HMOs, you will pay nothing when you visit doctors. With other HMOs there may be a copayment, like $5 or $10, for various services. If you belong to an HMO, the plan only covers the cost of charges for doctors in that HMO. If you go outside the HMO, you will pay the bill. This is not the case with point-of-service plans. Point-of-Service (POS) Plan. Many HMOs offer an indemnity-type option known as a POS plan. The primary care doctors in a POS plan usually make referrals to other providers in the plan. But in a POS plan, members can refer themselves outside the plan and still get some coverage. If the doctor makes a referral out of the network, the plan pays all or most of the bill. If you refer yourself to a provider outside the network and the service is covered by the plan, you will have to pay coinsurance.
There are many different insurance companies and many different insurance policies, and they have different eligibility requirements. In general, in the US most medical insurance is in the form of group insurance for employees of a given company. For the unemployed, it's a lot harder to get medical insurance. In other countries, insurance may be much more easily available. In Canada everyone is insured, by the government of the province in which they live.
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