Group health insurance helps employees and their families with the cost of medical care.
As part of benefit packages to attract employees, employers offer health insurance plans. Group health insurance plans usually offer health coverage for the employee and the employee's immediate family. Coverage offered may include everything from reimbursements for preventive care to catastrophic coverage. The Employee Retirement Income Security Act, ERISA, protects the rights of participants in most private-group health plans. ERISA provides information on health plans, as well as ensures that plan providers are compliant with ERISA rules and regulations, according to the Department of Labor.
HMO and PPO
Health management organizations, HMOs, and preferred provider organizations, PPOs, all fall under the realm of managed care plans. The difference between these plans is the level of freedom you have to see the physician of your choice and the amounts your insurer pays for the services you receive. With an HMO, you must select a primary care physician who will direct your medical care. Your insurer will pay for your care only if your primary care physician and the providers you seek belong to the HMO network. Further, certain services must be approved by your primary care physician. PPO plans offer network providers, but you can also see providers outside of the network. If you choose to go outside of the network, you will foot a portion of the cost.
POS and EPO
Managed care options also include point of service, POS, and exclusive provider organizations, EPOs. POS plans combine the characteristics of HMO and PPO plans in that there are in network providers from whom you may obtain service, but you may also see out-of-network providers. Out-of-network providers receive payment based on a fee schedule, and the fees they receive are usually referred to as "customary and reasonable charges." Exclusive provider organizations limit your care to providers in their networks only. Except in emergency situations, if you obtain care from a provider outside of the EPO network, you are responsible for 100 percent of the cost.
HSA and HDHP
Health savings accounts, HSAs, are meant to give you control over your medical dollars and help you save money for future medical expenses. The gist of these plans is that you deposit pre-tax money in a savings account. You pay no taxes on this money as long as you use the money for medical expenses; however, if you withdraw the money for any other purposes, you will pay a tax penalty. HSAs must be used in conjunction with a high-deductible health plan. High Deductible Health Plans, HDHPs, incorporate a higher deductible than most other plans, and you may be able to obtain preventive care services with lowered or no deductible applied, depending on your plan.
Other
Group health options can also include self-directed health plans. Members of a self-directed health plan, SDHP, fund accounts which are then used to pay for medical services. Sometimes, SDHPs contract with an insurer for administrative services only. Administrative Service Only, ASOs, plans take care of all administrative functions of the plan, such as claim payments and government reporting, and the insurance risk remains with the SDHP. Additionally, many plans offer prescription plans as a part of the plan package.
Tags: care physician, health plans, outside network, primary care, primary care physician