THE QUINTANA GROUP

What is individual and family health insurance?

Individual and family health insurance is a type of health insurance coverage that is made available to individuals and families, rather than to employer groups or organizations.

What kinds of individual and family insurance policies are available?

The major differences between plans are the choice of healthcare providers, up-front benefits and the maximum out-of-pocket costs.  Most plans make use of healthcare provider networks. Healthcare providers within a network agree to perform services for health plan members at negotiated discounted charges.  Most plans provide coverage when you use any provider, however, you'll have lower out-of-pocket costs when using network providers.

How does a PPO plan work?

As a member of a PPO (Preferred Provider Organization) plan, you'll be encouraged to use the insurance company's network of preferred doctors and hospitals. These healthcare providers have been contracted to provide services to the health insurance plan's members at a discounted rate. You typically won't be required to pick a primary care physician but will be able to see doctors and specialists within the network at your own discretion.

You will probably have an annual deductible to pay before the insurance company starts covering your medical bills. You may also have a co-payment for certain services or be required to cover a certain percentage of the total charges for your medical bills.

With a PPO plan, services rendered by an out-of-network physician are typically covered at a lower percentage than services rendered by a network physician.

How does an HMO plan work?

Though there are many variations, HMO (Health Maintenance Organizations) plans typically enable members to have lower out-of-pocket healthcare expenses but also offer less flexibility in the choice of physicians or hospital than other health insurance policies. As a member of an HMO, you'll be required to choose a primary care physician (PCP). Your PCP will take care of most of your healthcare needs. Before you can see a specialist, you'll need to obtain a referral from your PCP.

Generally, there is no coverage for services rendered by non-network providers or for services rendered without a proper referral from your PCP.

What is a co-payment?

A "co-payment" or "co-pay" is a specific charge that your health insurance policy may require that you pay for a specific medical service or supply. For example, your health insurance policy may require a $20 co-payment for an office visit or brand-name prescription drug, after which the insurance company often pays the remainder of the charges.

What is a deductible?

A "deductible" is a specific dollar amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance policy begins to make payments for claims. Generally, the deductible applies only to major medical expenses such as surgery or hospitalization.

What is coinsurance?

Coinsurance refers to the amounts that you and the insurance company pay for medical claims, usually after the deductible has been satisfied. For example, if your health insurance policy has a $1,000 deductible with 20% coinsurance, you would pay 100% the first $1,000 (the deductible), and then 20% coinsurance for claims exceeding $1,000.

What is the Out of Pocket Maximum?

The out of pocket maximum is the most you will pay out of your pocket for claims incurred in a calendar year.  Sometimes it is called the coinsurance maximum.  A plan with a $1,000 deductible and $4,000 coinsurance maximum, has an out of pocket maximum of $5,000.  For example, on a $50,000 claim, you would pay the first $1,000 (deductible) and then 20% of the next $20,000 ($4,000 coinsurance), for a total of $5,000.  Once you have satisfied your out of pocket maximum of $5,000 in a calendar year, the plan will pay 100% of your medical claims for the rest of the calendar year.

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