Health

**Open enrollment is 11/01/2016 – 01/31/17.  November 1st applications will start a January 1st effective date.

Whether you are an individual or employer interested in buying coverage or just looking for a quote, there are several different plans out there, and it is important to know the differences.

 

All of the plans are now categorized by Medal tiers: Bronze, Silver, Gold and Platinum.  Please keep in mind that if you are eligible for a tax credit, you can use that in any category; however, cost sharing is only available in the Silver category.

Please click here to view a video on choosing the correct category.

 

In Network: This means your provider has a contract with the health insurance network/carrier, and he/she cannot charge more than the agreed amount for a service.  Since there is an agreed amount, you tend to get better benefits on you plan by using an In-Network provider.

Out of Network: This means that you are using a provider that is not contracted with your health insurance network/carrier; therefore, he/she can charge more than the network/carrier deems a reasonable cost for a service.  You tend to get less benefits Out of Network rather than In Network, and on some plans, you may be balanced billed for the difference between what the doctor charges and what the health insurance network/carrier deems to be reasonable.

Health Maintenance Organization (HMO) – This type of plan usually requires you to pick out a primary care physician.  You will need to get a referral from that primary care physician in order to see a different doctor such as a dermatologist.  Referrals tend to be taken care of by the doctor and are usually electronic, which should eliminate inconvenience for you.  You do not need a referral to be covered in the Urgent Care or Emergency Room.  HMOs do not have any out of network coverage except for medical emergencies, and then you will be covered as though you are in the network.  Typically, HMOs tend to have richer in network benefits at a lower price since there is no out of network coverage.  This plan will utilize the HMO network of doctors.

Exclusive Provider Organization (EPO) – This plan is similar to an HMO because it had no out of network coverage except for medical emergencies. This plan will require you to pick a Primary Care Physician (PCP); however, it will not require you to get referrals to see other in network doctors.  In other words, you may self refer inside of the network.  This plan tends to be less in cost than a POS or PPO, but more in cost than an HMO because referrals are not required.  This plan typically will utilize the PPO network of doctors.

Point of Service (POS) – This type of plan will require you to choose a Primary Care Physician; however, you may go to any doctor in or outside of the network.  There will be higher plan paid benefits in the network verses out of the network in order to provide incentive for people to stay in the network for their medical services.  This plan will typically utilize the HMO network of doctors.

Preferred Provider Organization (PPO) – This type of plan does not require you to choose a Primary Care Physician.  You may utilize the in and out of network benefits at your convenience.  There will be higher plan paid benefits in the network verses out of the network in order to provide incentive for people to stay in the network for their medical services.  This plan will utilize the PPO network of doctors.

Health Savings Account (HSA) – This type of plan can be any of the above; however, it will have a high deductible as well as many out of pocket costs subject to the deductible that typically are not (for example; office visits, drugs, etc).  Deductible on HSAs are per family rather than per member, so you will be paying a higher deductible from the start.  You can set up a HSA compatible savings account at your bank, which allows you to put pre-tax dollars into it to use toward expenses on the plan.

Also, please beware, some plans use Aggregate deductibles rather than Embedded deductibles.  This means you may have to satisfy the entire family deductible before the plan starts to cover you rather than just the per person deductible.  This can definitely mean more out of your pocket.

Aggregate Deductible vs. Embedded Deductible definitions sited on the linked website.

Click on the carrier logos below to get individual quotes & sign up:

 

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Priority Health

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