What are health insurance coverage characteristics?

In general, health insurance covers the cost of medical or hospitalization care as a result of an illness or injury that occurs or is manifested while the policy is in force. Like other kinds of insurance, the benefits are payable in return for the insured paying a premium. A premium is the amount of money charged by the insurer for the coverage.

The coverage can be any one of a number of varieties, depending upon what is purchased:

1. Fee for service. This involves the health care provider billing the insurer for a fee, and the insurer paying all or part of it. Generally, there are guidelines that the insurer follows in determining the amount to be paid, and it is often determined by a community standard. The policy itself provides that the person insured must pay a portion of the charges per visit or occurrence (the deductible), and also what of usually called a co-payment. The latter reflects the fact that a policy may pay only a percentage of the allowable charge, for example, 80%. The corollary is that the insured pays the remaining 20%. In general, the larger the deductible and co-payment that the insured assumes, the lower the premium, because the insurer is at risk for less.

2. PPO. This stands for Preferred Provider Option. In a nutshell, healthcare providers agree to become a part of the insurer's network of providers, and pre-negotiate fees for stated procedures. An insured who is a member of a PPO typically sees a physician or goes to a hospital that is in the network, and gets the benefit of the reduced fee. The PPO pays the pre-negotiated rate, subject to the insured being responsible for a deductible and a co-payment (as discussed above). If the insured goes to a non-network provider, normally the deductible or co-payment is higher.

3. HMO. This stands for a Health Maintenance Organization. Ir is a form of what has become known as "managed care" and emphasizes preventive care. It has several models, including one involving in-house physicians, and one involving physicians who maintain their own practices but are devoted mainly to HMO patients. For a fixed monthly fee, the patient is entitled to a range of services. Costs are kept low because medical expenditures are monitored closely and permission is required to see an out-of-network provider.