Individual Health Insurance

Preferred Provider Organizations (PPOs)

This plan type closely resembles a Fee-for-Service plan. A PPO has arrangements with a network of doctors, hospitals and other providers who have agreed to accept lower fees from the insurer for their services. As a result, your cost sharing should be lower than if you go outside the network. In addition to the PPO doctors making referrals, plan members can refer themselves to other doctors, including ones outside the plan. This makes it a best-of-both-worlds option for many patients: lower costs in the network, but flexibility to leave the network if necessary.

If you go to a doctor within the PPO network, you will probably pay a copay (a set amount for certain services -- like $15 for a doctor visit or $10 for a prescription). Your coinsurance will be based on lower charges for PPO members.

If you choose to go outside the network, you will have to meet the deductible and pay coinsurance based on higher charges. You might also have to pay the difference between what the provider charges and what the plan will pay.

What kind of doctors are primary care physicians?

Usually, they fall into one of the following specialties:

• Family practice doctors or general practitioners
  These doctors are trained to diagnose and treat a variety of health conditions. If you are young and in good health, a general practitioner is your best bet. Many HMO members select the same general practitioner for their entire family.
  
• Internists
  Specializing in internal medicine, these physicians are trained to treat health conditions like diabetes and cardiovascular disease. If you are managing high blood pressure, heart disease or diabetes, an internist is a wise choice.
  
• Pediatricians
  These doctors only treat children, usually under the age of 12.
  
• OB/GYN
  Some plans allow women of childbearing age to select an OB/GYN as their primary care physician.

Guidelines in every plan

Whether you choose a Fee-for-Service plan, a PPO or an HMO, you will find that your plan has certain rules you have to follow.

Let's say you fall and break your leg while rock-climbing on vacation, and you are rushed to a hospital that is not part of your HMO network. Your emergency medical coverage is most likely included in your plan. After you've been patched up, however, the medical team feels you would be best served by tricky follow-up knee surgery. Chances are, either you or your doctor will have to call your insurance provider to get the go-ahead for the non-emergency treatment. This is known as "pre-authorization." It occurs when your insurer must approve a procedure before you actually have it.

Utilization review

Utilization review is a fancy term for the process used by plans to determine whether a specific medical or surgical service is appropriate or medically warranted. For example: You believe your severe neck pain will be alleviated by a new cervical disk surgery you read about on the Internet. You've talked to your physician about it, and he's familiar with the procedure, but the practice is not regarded as absolutely necessary for your condition. The Medical Review Specialist may be brought in to make the final decision about whether or not your insurance will cover the cost of the operation.