• Menu
  • Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar

Before Header

  • About Us
  • Lexicon
  • Contact Us
  • Our Store
  • ↑
  • ↓
  • ←
  • →

Balloon Juice

Come for the politics, stay for the snark.

Many life forms that would benefit from greater intelligence, sadly, do not have it.

The fundamental promise of conservatism all over the world is a return to an idealized past that never existed.

Ron DeSantis, the grand wizard, oops, governor of FL.

So many bastards, so little time.

Ah, the different things are different argument.

Republicans got rid of McCarthy. Democrats chose not to save him.

They traffic in fear. it is their only currency. if we are fearful, they are winning.

Narcissists are always shocked to discover other people have agency.

rich, arrogant assholes who equate luck with genius

Republicans: slavery is when you own me. freedom is when I own you.

The republican caucus is covering themselves with something, and it’s not glory.

“What are Republicans afraid of?” Everything.

Second rate reporter says what?

Too often we hand the biggest microphones to the cynics and the critics who delight in declaring failure.

No Justins, No Peace

Republican also-rans: four mules fighting over a turnip.

It’s easy to sit in safety and prescribe what other people should be doing.

Fani Willis claps back at Trump chihuahua, Jim Jordan.

Black Jesus loves a paper trail.

I really should read my own blog.

When someone says they “love freedom”, rest assured they don’t mean yours.

“Everybody’s entitled to be an idiot.”

Teach a man to fish, and he’ll sit in a boat all day drinking beer.

He imagines himself as The Big Bad, Who Is Universally Feared… instead of The Big Jagoff, Who Is Universally Mocked.

Mobile Menu

  • Four Directions Montana
  • Donate with Venmo, Zelle & PayPal
  • Site Feedback
  • War in Ukraine
  • Submit Photos to On the Road
  • Politics
  • On The Road
  • Open Threads
  • Topics
  • COVID-19 Coronavirus
  • Authors
  • About Us
  • Contact Us
  • Lexicon
  • Our Store
  • Politics
  • Open Threads
  • 2024 Elections
  • Garden Chats
  • On The Road
  • Targeted Fundraising!
You are here: Home / Anderson On Health Insurance / Plan types for your consideration

Plan types for your consideration

by David Anderson|  October 24, 20187:05 am| 13 Comments

This post is in: Anderson On Health Insurance

FacebookTweetEmail

During the open enrollment periods that many people either are in or will soon be in, plan types will be offered.  There are four primary plan types that are commonly offered and knowing the trade-offs in these designs would be useful.  Fundamentally each of the four plan types is a unique answer to two questions:  Does the plan require a Primary Care Provider (PCP) to act as a gatekeeper AND does the plan pay some non-emergency out of network benefits?  The directional answers to those questions will define plan types.

Point of Service (POS) plans require patients to go through their PCP for referrals to specialists and elective procedures.  There is an established network of contracted providers that will take payment in full from the insurer’s contracted rate but the patient can go out of network and at some point, the insurer will pay some proportion of the out of network claims costs.

Health Maintenance Organizations (HMO) are the most restrictive plans. There are no out of network benefits and patients are expected to go through their PCP before they see any expensive entity.

Exclusive Provider Organizations (EPO) remove the gatekeeper requirement from patients.  If someone wants to see a specialist, they can call and get an appointment in the network without worrying about denial of payment due to the lack of a pre-authorization.  EPOs don’t pay for non-emergency out of network care.

Preferred Provider Organizations (PPO) are the least restrictive plan types.  There is no gate-keeping requirement.  Out of network benefits are also available.  The out of network benefits tend to be far skimpier than the in-network benefit structure.

These are ideal archetypes.  Some insurers will offer HMOs that function a lot like EPOs with very light pre-authorization and gatekeeping requirements.  There are also PPOs that look a lot like POS in practice.  Finally, I am not mentioning indemnity plans which are network agnostic and pay out fixed fees for services.  Those plans are rare.

These four plan types are functional objects.  Any network can be attached to any plan type.  A narrow network could be attached to a PPO while a national network can be attached to an HMO or vice versa.  The same network can be attached to both the POS and HMO offered by a particular insurer.  An HMO, an EPO and a PPO can all have identical in-network benefit structures of identical deductibles, co-pays, co-insurance, service limitations and out of pocket maximums.

A policy is effectively a combination of a plan type, a network and a benefit design.  PPO and POS plans will have more complex benefit designs as they must have some type of out of network benefit in addition to the in-network benefits that all four types of plan need.  There are an almost infinite combinations that can be assembled between these three elements.  This increases the complexity of choice during Open Enrollment as individual preferences vary and the trade-offs between an HMO and a PPO will vary dramatically between individuals.  The trade-off between a higher deductible and lower premium HMO may be worthwhile for one person while a lower deductible and higher premium PPO is more attractive to a person who wants the option value of going anywhere in case they get hit by a meteor.

 

 

FacebookTweetEmail
Previous Post: « Wednesday Morning Open Thread
Next Post: Right-Wing Civility »

Reader Interactions

13Comments

  1. 1.

    PST

    October 24, 2018 at 8:13 am

    Interesting post, as always. Table needs fix on EPO abbreviation.

  2. 2.

    raven

    October 24, 2018 at 8:21 am

    So, I’m going to outline out situation again. I’m less than a year from retirement and my wife and I are both on BCBSGA HMO. When she broke her arm in Florida we learned that going anywhere but the ER was a big mistake when we were out of state. When I retire my organization gives us a set amount of money to buy insurance and I have to go through AON to purchase insurance. My wife stays on BCBS until she reaches 65, 5 years from now. I’m wondering if I should look at one of the other options we have during open enrollment so she’d be on a better plan. I don’t really know if she’s stuck on what we have when I retire or if she selects during open enrollment.

  3. 3.

    David Anderson

    October 24, 2018 at 8:23 am

    @raven: First advice — go talk to a broker; some states will allow brokers to charge you an advice fee where they are not selling you anything but you are buying their time and expertise for an hour. That should be your first stop.

    Secondly, figure out how valuable out of network coverage is to you and look into the trade-offs.

  4. 4.

    Butch

    October 24, 2018 at 8:47 am

    So, David, when I lost corporate insurance last June I went on the Exchange looking for coverage; the Bronze plan here basically amounted to buying a premium so I found an underwritten plan. However, for some reason a month later I started getting bills for Bronze plan coverage that I had neither requested nor approved, and it took a lengthy appeals process to get the bills to stop (and protect my credit rating). I’d really prefer a policy that complies with the ACA over this underwritten one, but after that experience I’m a little shy about going on the Exchange and am not sure the price could have dropped enough to make the visit worthwhile. (Bronze plan was $700 a month per person with a ridiculous deductible; the underwritten plan is $350 with a much more reasonable deductible. It excludes mental health and drug addition coverage but we don’t need either.)

  5. 5.

    raven

    October 24, 2018 at 8:55 am

    @David Anderson: Great, we actually have a Council on Aging with counselors available as well. Nest stop! thanks

  6. 6.

    raven

    October 24, 2018 at 9:22 am

    Nows that I look at our choices it seems lioke it’s BCBS or Kaiser HMO and folks in these parts aren’t crazy about Kaiser.

  7. 7.

    rachel

    October 24, 2018 at 9:36 am

    Quick question: is there an authoritative site that tracks changes and rates of changes in health insurance rates pre-and-post-ACA?

  8. 8.

    Aurona

    October 24, 2018 at 9:48 am

    I continually look for the right plan for my good health 7.1 decades in, and this Medicare year in Seattle, it’s a PPO from Humana with $0 premium, $0 primary doctor, $3600 maximum out of pocket (MOOP), my current PolyClinic, but with no Rx attached. I pay separately for EnvisionRxPlus for about $16 monthly, and I take no drugs. Also this plan has a drip of other benefits (gym, some eye, dental, hearing), but the moop did it for me. I don’t find the preventive dental good enough for me, so I do have a separate Delta Dental plan ($50 premium, $2000 max/beginning 2nd year, $0 copay). So for $66 a month, I feel this is the best plan for me. Thanks for keeping me aware and on alert for the changes to both the plans and to my health needs.

  9. 9.

    David Anderson

    October 24, 2018 at 10:26 am

    @rachel: Charles Gaba at ACASignups.net is pretty close to the go to source

    Kaiser Family Foundation is a fountain of knowledge as well.

  10. 10.

    Humdog

    October 24, 2018 at 10:41 am

    I wish I could find an explanation as to why we have such a doctor shortage. My husband needs a doctor as he let his prior relationship lag for 8 years but there is no doctor in the county accepting new patients regardless of insurance coverage. He is recording crisis level blood pressure readings and his only option is emergency room, when all he needs is a few minutes to write a prescription.
    U.S. docs supposedly pull in big bucks so why don’t we have a surfeit of them like we do lawyers? We are importing doctors from outside the US and still not enough GPS. Why aren’t the PTB opening more med school slots? I simply don’t understand.

  11. 11.

    rachel

    October 24, 2018 at 10:57 am

    @David Anderson: Thanks.

  12. 12.

    debbie

    October 24, 2018 at 6:23 pm

    There are two options at my work. Lower cost / higher deductible vs. higher cost / lower deductible. I choose wrong every freakin’ year. I’m going to stop even trying.

  13. 13.

    debbie

    October 24, 2018 at 6:27 pm

    .

Comments are closed.

Primary Sidebar

Recent Comments

  • Jay on Wednesday News Roundup, A Little Late (Apr 18, 2024 @ 12:54am)
  • Chet Murthy on Wednesday News Roundup, A Little Late (Apr 18, 2024 @ 12:54am)
  • NotMax on Wednesday News Roundup, A Little Late (Apr 18, 2024 @ 12:51am)
  • Jay on War for Ukraine Day 785: Chernihiv Attacked! (Apr 18, 2024 @ 12:51am)
  • Chet Murthy on Wednesday News Roundup, A Little Late (Apr 18, 2024 @ 12:50am)

🎈Keep Balloon Juice Ad Free

Become a Balloon Juice Patreon
Donate with Venmo, Zelle or PayPal

Balloon Juice Posts

View by Topic
View by Author
View by Month & Year
View by Past Author

Balloon Juice Meetups!

All Meetups
Talk of Meetups – Meetup Planning
Proposed BJ meetups list from frosty

Fundraising 2023-24

Wis*Dems Supreme Court + SD-8
Virginia House Races
Four Directions – Montana
Worker Power AZ
Four Directions – Arizona
Four Directions – Nevada

Featuring

Medium Cool
Artists in Our Midst
Authors in Our Midst
Positive Climate News
War in Ukraine
Cole’s “Stories from the Road”
Classified Documents Primer

Calling All Jackals

Site Feedback
Nominate a Rotating Tag
Submit Photos to On the Road
Balloon Juice Mailing List Signup
Balloon Juice Anniversary (All Links)
Balloon Juice Anniversary (All Posts)

Fix Nyms with Apostrophes

Balloon Juice for Ukraine

Donate

Twitter / Spoutible

Balloon Juice (Spoutible)
WaterGirl (Spoutible)
TaMara (Spoutible)
John Cole
DougJ (aka NYT Pitchbot)
Betty Cracker
Tom Levenson
David Anderson
Major Major Major Major
ActualCitizensUnited

Political Action 2024

Postcard Writing Information

Balloon Juice for Four Directions AZ

Donate

Balloon Juice for Four Directions NV

Donate

Site Footer

Come for the politics, stay for the snark.

  • Facebook
  • RSS
  • Twitter
  • YouTube
  • Comment Policy
  • Our Authors
  • Blogroll
  • Our Artists
  • Privacy Policy

Copyright © 2024 Dev Balloon Juice · All Rights Reserved · Powered by BizBudding Inc

Share this ArticleLike this article? Email it to a friend!

Email sent!