The health insurance industry has grown considerably in the past decade. According to the latest figures from the National Association of Insurance Commissioners, enrollments are up despite a slight increase in premiums, and the industry is estimated to be worth over $189 billion. Put simply, a growing number of Americans are signing up for various medical insurance plans. But what types of plans are available, and how can you benefit from them?
Here’s your ultimate guide to the numerous types, uses, and benefits of health insurance plans.
Health Maintenance Organization (HMO) Insurance
HMO medical insurance plans only provide coverage for services that are contracted by the insurance provider. They also require policyholders to choose a primary care physician with whom they’ll get most of their plan’s benefits. There’s limited provision for out-of-network care and policyholders might be required to live/work in a specific service area to be eligible.
For example, suppose you sign up for the Sharp Platinum 90 HMO Performance plan. According to this plan’s summary of benefits and coverage, the out-of-pocket limit is just $3,350 per individual and the cost of using an out-of-network provider is higher than using a provider contracted by Sharp HealthCare. Moreover, this plan is only available to residents of San Diego.
Preferred Provider Organization (PPO) Insurance
Like HMO plans, PPO plans exclusively provide coverage for services contracted by the insurance provider. However, PPO plans aren’t limited to one location, and there’s no need to choose a primary care physician. No matter where you’re living and/or working in the country, if you’re on a PPO health insurance plan, you’ll receive coverage as long as the facilities you visit are part of the provider’s network.
Let’s take the Platinum 90 Ambetter PPO plan as an example. Signing up for this plan will entitle you to several benefits like complimentary preventative care services and 90% off medical imaging. The only catch is you must visit a facility that belongs within the EnhancedCare. Network.
Exclusive Partner Organization (EPO) Insurance
EPO medical insurance plans don’t provide coverage for out-of-network doctors and specialists except during medical emergencies. Moreover, many EPO plans only provide coverage for medical necessities. In contrast, some HMO and PPO plans cover voluntary medical procedures.
For example, Blue Shield California’s EPO health insurance plans don’t cover services received from out-of-network providers as per the general exclusions and limitations section (clause 1) of their important disclosures document. Moreover, the plan only covers procedures Blue Shield deems medically necessary (clause 2).
Uses & Benefits
There are three kinds of EPO/PPO/HMO plans on the market: individual health insurance, dental insurance, and employee health insurance. Each type of plan has its own uses, application process, and unique benefits depending on the coverage. Continue reading to find out more!
Individual Health Insurance
As the name suggests, individual health insurance plans are used by individuals from all walks of life. Whether you’re a parent looking for medical insurance for your child or an international student looking for health coverage having just arrived in the US, your best bet is to take out individual health insurance.
If you want to sign up for an individual health insurance plan, the first step is to speak to an insurance agent. Why? Because different plans suit different circumstances. We recommend arranging an appointment with an insurance agent to explain your personal circumstances as succinctly as possible. If you’re unsure what to tell their team, ask yourself the following questions—what’s your health insurance budget? How often do you and/or your dependents go to the doctor for remedial care? Are you interested in preventive care? Are you expecting? By telling the insurance agent the answers to these questions, you’ll help them understand your unique circumstances. This will help the agent suggest plans that are right for you.
One of the main benefits of individual health insurance pertains to costs. Some individual health insurance plans come with tax credits that the holder can use to lower their monthly insurance premiums. Moreover, many medical insurance providers offer plans that charge a single amount to cover individuals and their dependents. For example, if you sign up for the Sharp Silver 70 Off Exchange Performance HMO plan, you won’t be asked to pay out-of-pocket for preventive care services like well-child visits for your kids up until they turn 18.
Another major benefit of individual health insurance plans is uniqueness. For instance, suppose your employer signs the entire company’s workforce to one group insurance plan. What happens if you or your dependents require coverage for a medical condition the employer group insurance plan doesn’t provide? In this scenario, you’re better off with an individual medical insurance plan that provides coverage for the treatments you and your loved ones require at a price within your budget.
If you’re seeking medical insurance that gives you maximum flexibility, individual health insurance is for you. Unlike employer group insurance, coverage for individual health insurance plans doesn’t end if you leave a company. Moreover, individual health insurance plans aren’t limited to one field of medicine in the way dental insurance plans are. Once you sign up for an individual health insurance plan, you’re in the driving seat when it comes to what type of coverage you want, how much to pay, and when to leave.
Dental insurance services primarily cover all manner of dentistry services. This typically includes preventive care through periodic oral exams at the dentist’s office as well as teeth cleaning and x-rays. With that said, the exact coverage varies from plan to plan.
People with recurring dental issues often sign up for dental insurance to save money on remedial care. For instance, if you’ve got a periodontal disease that might cause you to lose your teeth prematurely, it’s worth being on a comprehensive dental insurance plan that provides discounts on expensive procedures like getting premium dentures.
Dental insurance plans don’t have as many clauses as other types of medical insurance because they only focus on one part of your body. However, the average joe would still struggle to understand dental insurance service terms and conditions—especially if they’re unfamiliar with medical jargon. Therefore, we recommend consulting an insurance agent who specializes in dental insurance about what plans to apply for. They’ll help you understand the terms of the various dental insurance plans on the market before recommending one that suits your needs. They’ll also walk you through the application process and take care of the paperwork.
Preventing Life-threatening Issues
If you asked the average joe whether dental issues are deadly, chances are they’ll say no. But did you know this isn’t true? If your dental health is poor, there’s a high chance that bacteria will make its way into your bloodstream through your gums and potentially cause internal infections. Moreover, if plaque from your teeth makes it to your bloodstream and settles on the valves of your heart, you could suffer a heart attack.
Fortunately, preventing these potentially life-threatening issues is as easy as signing up to a dental insurance plan provides easy and affordable access to a dentist. If you’re struggling to decide between various dental insurance services, we recommend speaking to an insurance agent.
Ensuring Children Grow Up Healthy
This benefit is an off-shoot of preventing life-threatening issues, but we felt it deserved its own section. We cannot stress how important it is to ensure your kids go to the dentist regularly as they grow. Why? Because most oral health issues start during childhood. In other words, if you don’t want your kids going through the anxiety of getting treatments for advanced dental health issues when they’re older, put them on a dental insurance plan early.
If you look at the fine-print on dental insurance plans, you’ll realize most of them cater to specific dental conditions. For instance, Anthem Blue Cross offers five types of Essential Choice PPO dental plans that provide coverage for different ailments. The Bronze plan covers tooth removal, gum treatments, and preventive care, while the silver plan also covers root canals, crowns, bridges, and cosmetic teeth whitening. This is highly beneficial because it allows people to select plans that specifically benefit them.
Employer Group Insurance
Employer group insurance is for businesses interested in providing medical insurance for all their staff. It covers many of the same health services as individual health insurance such as pre-natal and post-partum care. However, group insurance can only be used by the employees of the company providing it.
Companies that provide group insurance cover a portion of each employee’s health insurance premium. The remaining portion of the premium is covered using deductions from the employee’s salary. Many group insurance services also provide coverage for employees’ dependents.
Companies typically consult an expert insurance agent on various group insurance policies before deciding on the ones they’d like to offer their employees. The insurance agency subsequently takes care of the application process and submitting all the paperwork to the insurance provider.
This means that if you’re a member of staff and your employer offers you group insurance, chances are you’ll be shown the terms and conditions and asked whether you’d like to accept. With that said, it’s common for astute employees to contact the insurance provider their company is working with directly to find out more about their plan. This minimizes the chances of information gaps causing you to misunderstand your policy coverage.
Cheaper for the Employee Than Signing Up for Individual Health Insurance
According to the California Health Care Foundation, Californians pay 25% of their group insurance premiums and the average premium per adult employee (including the employer’s contribution) is $653 per month. In other words, Californians with employer health insurance pay just $163.25 per month in premiums. To put things into perspective, the cheapest individual health insurance plan by Sharp HealthCare that provides bare-bones coverage is $199.97 for adults aged 18!
Boosts Employee Retention for the Company
Want to stop employees from leaving your company? It’s time to think about giving them group insurance as a work benefit. No matter what industry you’re in, better remuneration packages positively correlate with employee retention. However, some companies don’t have the budget to give their staff members salary bumps to discourage them from leaving. Employer group insurance is a terrific middle-ground—it’s a cheaper alternative to salary increments and employees are likely to view it as a sign their employers care about their well-being.
Improves Company Image in the Eyes of Prospective Employees
Another fantastic benefit of group insurance is that it helps your company stand out to prospective employees. Companies that market employer group insurance enthusiastically are likely to attract top talent—especially if the plan provides industry-specific coverage.
Covered California Certified Agent Provides Expert Advice on Individual, Dental, and Employee Health Insurance in California
Looking for an insurance agency in California that specializes in all three types of medical insurance we’ve discussed in this article? If so, look no further than Covered California Certified Agent.
We’ve helped numerous businesses browse and pick employer group insurance plans within their budget that provide their employees with adequate coverage. We also help Californians understand and apply for both individual and dental insurance. Our seasoned insurance agents always strive to provide fantastic value for money for our clients and place love and care at the heart of everything they do.
Dial 800-771-7653 today to book an appointment with a top health insurance agency in California.