PPO Individual Health Insurance

The preferred provider organization (PPO) in PPO individual health insurance is an arrangement for claims processing that may appear like a combination of traditional fee-for-service and an HMO. Like an HMO, the PPO has a limited number of doctors and hospitals to choose from in-network. When you use those providers (sometimes called "preferred" providers, other times called "network" providers), most of your medical bills are covered.

When you go to doctors in the PPO, you present a card and do not have to fill out forms. Usually there is a copayment for each visit. For some services, you may have to pay a deductible and coinsurance.

insurancebrochure PPO Individual Health Insurance Quotes

Unlike an HMO, a PPO plan usually does not require that you choose a primary care doctor to monitor your health care. Some PPO individual health insurance may cover limited preventive care, some cover none. This usually includes visits to the doctor, well-baby care, immunizations, and mammograms.

In individual health insurance, you can use doctors who are not part of the plan and still receive some coverage. At these times, you will pay a larger portion of the bill yourself (and also fill out the claims forms). Some people like this option because even if their doctor is not a part of the network, it means they don't have to change doctors to join a PPO plan.

Questions to Ask

POS Individual Health Insurance

Point-of-service is abbreviated to "POS". POS individual health insurance usually means an HMO plan combined with indemnity coverage giving the insured a constant choice of who to see for medical services. There is a lot less out-of-pocket cost to the insured if the network providers are used. Using out-of-network providers increases claims costs and to discourage that, the out-of-pocket expense is much greater to the insured.

Individual Health Insurance Quotes

POS signifies that the insured pays a different amount depending on where the insured goes for treatment. The insured pays less in-network and more out-of-network.

A primary care provider may have to be selected for the HMO portion of POS coverage, but of course there is usually none for the indemnity part if you want to go direct to out-of-network specialists.

The HMO part of POS individual health insurance is usually copays only, although deductibles and coinsurance are starting to be introduced. The indemnity part of POS coverage is typically always deductible and coinsurance only with no copays. Copay means a small payment by the insured at each medical visit or service. Coinsurance means paying a percentage of medical expenses up to a certain figure each year, e.g., 20% of the first $5,000 after deductible is paid, then the insurance company pays 100%. Besides lower out-of-pocket exposure with the HMO, there is also the advantage that claims will be filed by the provider, wheras with out-of-network providers in the indemnity part of POS coverage, the insured may have to file and keep track of claims.

Point-of-Service (POS) plans usually have a higher premium than an HMO with similar benefits and may not be available for individuals to buy.

Questions for POS coverage

Incorporates Source document:   Checkup on Health Insurance Choices. AHCPR Publication No. 93-0018, December 1992. Agency for Health Care Policy and Research, Rockville, MD.

¶ Nothing here constitutes advice or recommendation of any nature, whether legal, tax, financial planning or otherwise. The comments above represent only the author's understanding of individual health insurance and may be incorrect or out of date.

Individual Health Insurance