Business FAQs

Group Health

PPO Plan Features

Convenient access to quality medical care for employees
Large and diverse network available of primary care physicians, specialists, hospitals & clinics.

PPO Insurance Plan
A PPO group health insurance plan is recommended for a business desiring to offer their employees convenient access to quality medical care with effective medical management, a large and diverse network of primary care physicians, medical specialists, hospitals and clinics.

An employee can see any health care professional in the network any time they choose to make an appointment. They don't need referrals for specialists or other services as required in an HMO. An employee can see doctors or specialists outside your PPO network, however, your employees portion of the costs will be higher.

An employee may have to pay some portion of the cost (co-payment) for each office or hospital visit, such as $20 per doctor visit, regardless of what the services cost. Also, some services such as emergency room, mental health and chemical dependency services, may carry additional
costs in a PPO health insurance plan.

HMO Plan Features

Preventive care emphasis
Primary care physician coordinates the total care of the employee

HMO Insurance Plan

An HMO group health insurance plan helps your business control health care costs through a closely managed plan with an emphasis on preventive care. Each employee selects a Primary Care Physician from a network of providers. The Primary Care Physician can coordinate the total care of the employee to help ensure appropriate care is received. An employee may also seek care from any provider in the network without a Primary Care Physician referral, subject to a higher out-of-pocket expense.

Subscribers to an HMO receive medical services from participating physicians, clinics and hospitals. An employee chooses a primary care physician from a list of participating doctors. That doctor is used for typical circumstances such as annual exams and usual health issues. If the employee needs to see a specialist, be hospitalized, or have lab or X ray work, their doctor will refer them to a provider or facility within the HMO system. Your employees doctor must give authorization for those services to be covered by your HMO. In other words, an employee must see HMO approved physicians and use HMO approved facilities or pay the entire cost of the visit themselves.

Similar to Point-of Service (POS) and PPO's, HMO's have made arrangements for lower fees with a network of health care providers and give their policyholders a financial incentive to stay within that network.

An employee may have to pay some portion of the cost (co-payment) for each office or hospital visit, such as $20 per doctor visit, regardless of what the services cost. Also, some services such as emergency room, mental health and chemical dependency services, may carry additional costs in a HMO health maintenance plan.

POS Plan Features

Preventive care emphasis
Pays benefits for out-of-network care, but at a lower level

POS Insurance Plan
A POS or Point-of-Service group health insurance plan allows your employees the option of accessing any medical provider without a primary care physician referral and receive the highest benefit level. Similar to an HMO, a POS stresses preventive care and offers closely managed benefits. A POS health insurance plan also pays benefits for out-of-network care, but at a lower level than for in-network care.

Costs that exceed the deductible are covered by a co-insurance plan in which your employee and the insurance company share the cost for services covered by the policy. Also, some services such as emergency room, mental health and chemical dependency services, may carry additional costs in a POS health insurance plan.

Fee-for-Service
Fee-for-Service or major medical group health insurance provides benefits up to a high limit for most types of medical expenses incurred, subject to a deductible. Once the deductible is met, this type of group health insurance plan will pay a percentage of what is considered the "Usual and Customary" charge for covered services. The insurance company generally pays 80% of the Usual and Customary costs and you're responsible for paying the other 20%, which is known as co insurance. If the insurance company charges more than the Usual and Customary rates, you will need to pay both the co-insurance and the difference.

Fee-for-Service group health insurance allows your employee to choose their doctor and any hospital for their medical services. Usually, an employee will have a deductible such as $500 or more to pay each year before the insurer starts paying. The plan will pay for charges such as medical tests and prescriptions as well as from doctors and hospitals.

Fee-for-Service health insurance coverages for employer sponsored employee benefits in typically offer the following:

Employers and employees share premiums
Employees have the freedom to choose any provider
Insurance company pays the allowable claim

Fee-for-Service plans also offer some Managed Care type of insurance options that can assist your business in reducing employee benefit costs.

Case Management
Second Surgical Opinion
Pre-admission Certification
Special Benefit Networks

Fee-for-Service group health insurance coverages offer more choice of doctors (including specialists, such as cardiologists and surgeons), hospitals, and other health care providers than managed care health plans, such as HMO, PPO, and POS. Fee-for-Service employee health insurance may not pay for some preventive care, such as check-ups, and is usually a more expensive health insurance coverage than utilizing an HMO, PPO, or POS plan.