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Individual Health Insurance Benefits

When you are looking for an individual health insurance policy you may be wondering how much your plan covers, how much you yourself will have to pay for care, and what kind of benefits you will receive. It is important to know this before choosing a policy — to make sure you get the right policy for you and your needs.

In the case of Managed Care plans, the medical services that are covered are specified in the plan and you will be provided with a break down of the cost you are responsible for. You may be entitled to doctors and hospitals that are outside of the plan network, but these may end up costing you more.

  • Managed care plans seek to deliver the quality care that is most appropriate and relevant to the patient, while still remaining affordable. The major three types of managed care plans are PPO, POS, and HMO plans.
  • Preferred Provider Organizations (PPO) plans are similar to HMO plans in some ways. Members enter into a contract with health care providers to form a network. However, in some cases you may go outside of the network for health care and a percentage may still be covered. Members are not assigned a primary caregiver and those who choose to use the provider network will have the benefit of lower deductibles.
  • Health Maintenance Organizations (HMOs) consist of a contract entered into between the patient, insurance company and specific healthcare providers. These people form a provider network. Members must only see doctors, hospitals and other providers that are within this network. HMO plans will not pay if you go outside of the provider network.

    If you are a member of an HMO, you will pick a primary caregiver who oversees your medical care, coordinates any treatments, and authorizes any decisions that need to be made regarding your care. While HMOs are the most restrictive plans in terms of care, they are also the cheapest and provide the most extensive care for the least amount of money.
  • Point of Service (POS) plans are sometimes referred to as ‘open ended’ plans. It is basically a hybrid between PPOs and HMOs. These plans give members the choice of which option (PPO or HMO) they wish to use every single time they need health care. Members are urged to choose a primary caregiver, but it is up to the member’s discretion. Patients can opt out of using network providers, with an increase in copayments.

You will want to familiarize yourself with the different types of deductibles and maximums when choosing a policy.

Coinsurance maximums are an annual cap that you’ll have to meet. Basically, until you reach that maximum dollar amount, you’ll be required to pay a small percentage of your medical bills. You’ll also have an out of pocket maximum. This is the figure that you’ll be responsible for paying over one year. It includes deductibles, copayments and coinsurance. Once that figure is reached, the plan will cover all of your medical bills for the remainder of the year. Lastly, you have deductibles. A deductible is the amount that you have to pay before the insurance company starts paying for health care services.

You may notice that in your plan you are responsible for copayments or co-insurance, where you pay a partial amount of the medical bill, for several different types of medical care. This is common practice for most health insurance policies. These usually include office visits, non-emergency hospital visits, outpatient care, maternity care, preventative care in some cases, and emergency hospital care, such as visits to the ER. You may also have to pay a percentage of the bill for things like prescription drugs, nursing care, physical therapy, lab tests, and x-rays. Find out what your policy covers and how much you will be responsible for. It depends on the type of insurance you have, and what provider you use, in most cases.

Individual Health Insurance Terms

Lifetime Maximum
This is the total amount that your individual health insurance will pay for your medical care for as long as you have the policy.
This is the amount the patient must pay for health care before individual health insurance covers the cost.
These are predetermined fees that the patient must pay for health care, in addition to what the individual health insurance will cover. This is usually a small flat rate.
Money that the patient is required to pay for services, after the deductible has been paid. These are very similar to co-payments, but deal in percentages whereas co-pays do not.
Primary Care Physician (PCP)
This is the person assigned to oversee your care and authorize medical decisions, appointed by the provider network in the case of managed care.
Sometimes referred to as the provider network. This is a group of doctors, hospitals and other health care providers that are contracted to the insurance companies to provide health care for less than their usual fees. They also offer a wider range of services.
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