ALL RIGHT. I’ve visited a ton of websites, gotten instant health insurance quotes, and seen plenty of brightly colored benefit descriptions with deeply moving little scriptures. What does this all mean (and who is writing this nonsense)?
Although we didn’t write it down, we narrowed down the various plans to 5 essentials after reading them for years. If you only understand these points, then. And the. You’ll have enough confidence (and stay sane) to enter the California health insurance market.
Now granted, there are tweaks and variations between shots, but with the five points above, you already know about 90%. Ask about the remaining 10%.
let’s start. Hmo, pco and epo. What does all this mean? We will consider them carefully, but the main thing is to understand what they are. How their actions affect your care. Look at it closely.
1. Understanding the HMO, PPO, and EPO insurance networks in California and how they affect you.
HMO extension. PPO extension. What does all this mean for the European Patent Office? GOOD. We get to the bottom of each term and, more importantly, how it affects you, rather than giving you a long version of what it means.
I will start with a trip down memory lane. The mid-1980s was up to (F. In California, health insurance was relatively simple at the turn of the century. Any doctor could be visited, and the insurer offered a certain amount. However, it was at this time that “assistance” appeared and suddenly words like HMO and PPO and EPO What are they exactly?
These are essentially volume discounts.
To control the costs, the insurance company went to the doctors and told them: “Listen. If you join our PPO, we will give you many customers (we are the insured), but we ask you to reduce your rates 30-60%. Doctor visit should cost $100 or $60. In addition, if you join our HMO, we will pay you $50 per month for each new member you join. In return, there will be a lot of people to compensate for this reduced amount.
Insurance companies and doctors now have different contracts, but they usually offer deep discounts to help control medical cost inflation. From the early 90s to around 1997. And it worked. On the premium front, everything was pretty quiet. As premiums have increased dramatically since 1998, we may be reaching the limit of what managed care can achieve.
Now that we have an overview of what an HMO, PPO and EPO are, from a doctor’s perspective. How do they influence us?
Let’s separate each of them first.
The HMO (Health Maintenance Organization) is the exact opposite of the old method (Fee for Service), which allowed you to consult the doctor of your choice. As a general rule, all care is managed by the initial doctor selected as well as a nearby hospital and doctor’s office. Most care decisions and/or referrals are made by this physician, known as the primary care physician. The benefits of this highly structured system are very rich, but there is a trade-off. That is, low reimbursable expenses if you are injured or ill. Some people strongly believe in it. Others curse him. It is suitable for those who appreciate flexibility and low direct costs. In general, HMOs are not offered in rural areas. Considering they require many people to make it work, dot.
Going back to our spectrum, Preferred Provider Organizations (PPOs) fall between the old “go see any doctor” and “choose any doctor/hospital” HMO approaches. In California, you can choose from a long list of doctors and medical facilities. You can search for quotes on your own and you are not limited to any particular area or doctor. With a PPO plan, you get negotiated rates (30-60% off mentioned above), which can lead to significant savings. As a result, you will contribute to the cost along the way. Either as a percentage or as a deductible (more on this in section 4). Currently, PPOs allow you to see a doctor who is not in the network, but your benefits will be significantly reduced. Why? These doctors do not offer the “volume reduction” we talked about earlier.
An EPO (Exclusive Provider Organization) is a different, less common variant. EPOs have no out-of-network benefits, but have the exact same doctors and hospitals as PPOs. No benefits are granted if you consult a doctor who is not on the EPO list.
2. Premiums. The monthly payment you must make to maintain the policy is indicated by a dot. Still, there’s more.
Great subject. The cost of health insurance. Your blood pressure can rise even just thinking about it, often faster than it actually does. Find out why an expensive plan isn’t always the best plan by taking a closer look.
The contract is quite simple. If you continue to pay the premiums. Before taking a look at the big and small bills, . The insurance company will cover you, but what exactly do we pay? .S, etc. You need to understand a basic fact about health insurance.
So you receive great benefits for lower costs. Do not trust me. Your payment covers this. It’s similar to buying a car warranty that also includes a weekly car wash, an oil change every 3,000 miles, and new tires every two years. However, the price will be very expensive. Health insurance is very similar to it; No one can afford it.
This can be explained using a direct example from real life.
Keep in mind that you are paying $47 per month for a high deductible PPO plan which basically pays for the big expenses. You are responsible for all minor details. As an alternative, consider a 30% PPO plan that will cover you immediately for $167 per month. You will owe 30%. This means that a visit to your doctor will be quite affordable. Just keep in mind that they will handle large bills the same way.
Our $47 plan has now garnered the first response. It doesn’t seem like a good idea to have to pay for doctor’s visits and all that amounts to $2,250.
But let’s take a closer look. The additional premium is $120 per month. In an annual sense, this equals $1,440. To take advantage of the most expensive package, it is better to have a lot of small bills. Therefore, you pay a fixed amount of $1,440 for a potential expense of $2,250. This type of insurance is not wise. What you want is to pay pennies on the dollar. 1.e. Avoid a potential surgery bill of $20,000 or more with a monthly investment of $47.
3. The main reason to purchase health insurance in California. The “Big What-if.”.
I hear it almost daily. “I am in good health, why do I need health insurance?”.
Every seven years, the average person visits a hospital. Nearly half of bankruptcies in the United States result from a medical emergency or accident. . And take my word for it. Maybe they were all healthy.
In the field of medicine today there is a double-edged sword. With more progress on the horizon thanks to recent genetic advances, medical technology and capability has never improved much. All of this is great, but the costs also increase as capacity increases. Your health insurance should ultimately protect you against the possibility of a huge medical bill, because that’s the main reason you need it.
maximum amount disbursed.
Perhaps the most important aspect of your medical plan, most plans deal with that great “what if” health coverage or “pocket max” catastrophic health coverage.
Essentially, it’s about when the plan will pay 100% of your expenses if you have a big bill (or multiple bills). Of course, this ceiling applies both to covered services and to network services (see Section 1 Doctor of the Doctor). It usually runs from January to December each year, after which it resets. The maximum usually includes the discount (we’ll discuss the discount in the next section, “Small Invoices”).
4. A look at how insurance plans handle the smaller bills: Pennies on the Nickel.
From now on, when we talk about small bills, we are mainly talking about your maximum disbursement (see Section 3 – Big bills). Let’s take a look at them and, more importantly, the different ways each plan deals with these costs. will be your expense. Ted.
Each plan handles small bills in one of three ways, up to the maximum amount you have. Small expenses include everything from a co-payment for a doctor’s visit to a minor procedure. Basically, circle everything below the max limit (because everything increases by 100% after that!!). Before defining the actual cost of bells and whistles, let’s first define these terms.
Deductibles, coinsurance and coinsurance.
The deductible is a sum of money that you are responsible for paying in full before your insurance starts paying. Think of it like a bank account. The insurance then begins to pay once you have exhausted your personal funds. This amount generally corresponds to the calendar year, from January to December. There are sometimes different discounts for certain types of care, such as maternity care. Now keep in mind that if you are inside the network, i. E. Due to negotiated prices and the fact that you are a Blue Cross member and the physician is a Blue Cross physician, you will receive a 30-60% discount. Let’s examine the illustration.
The cost of doctor visits is $100. This fee can be reduced to $60 because you and your doctor are both members of a Blue Cross PPO. The deductible applies to the $60 you pay.
Even before having reached the total amount of your deductible, this negotiated price is a great advantage. Today’s market primarily offers what is known as a high-deductible plan (ranging from $1,000 to $3,000), which is for people who are very concerned about the “what ifs” and want to keep their monthly premiums at a low level. A good example is the Health Savings Account plan, which offers special tax benefits to individuals and small businesses.
Participation is only the cost of a particular service. For example, a $40 co-pay usually means you’ll pay $40 for a doctor’s visit. Note that additional services, i. E. Tests, x-rays, etc. will incur additional charges. On some services, there are sometimes subscriptions. Attendance may be required, for example, for an ambulance or emergency room visit.
When you co-insure, you agree to pay part of the cost of the services. A 30% plan, for example, means you will pay 30% (insurance pays 70%) of the agreed rate.
Basically, the insurance plan handles small expenses in one of three ways.
5. How insurance companies handle the part of going to the doctor that is getting more and more expensive. Prescriptions with a dot.
Despite the rhetoric of politicians, brand prescriptions are growing at 20% per year. That probably won’t change for some time.
In case you haven’t been around for a while, pharmaceutical companies have changed the way they promote their products. The doctor was the main channel through which they marketed. “pushing” techniques. Now they are going directly to you, the consumer, with big advertising campaigns in the hope that you will go to your doctor and order this drug. Use the “pull” method. imagine that. You want to make sure your insurance plan covers the cost of all of this, because there is one.
Most insurance plans process prescriptions through co-payment, which is a fixed amount you must pay. Due to the circumstances I mentioned above, there is usually a different combined amount for brand name drugs and generic drugs. Typically, you’ll find a $10 and $25 copay for the brand, but be sure to check the policy. It is possible that this will change.
Well, we did. Hopefully with some reductions and a much better understanding of how to read blueprints.
