What is a Major Medical Plan?

Posted by Admin on June 1, 2015 in Health Insurance |

When you begin to look for New York health insurance, you will encounter something called a major medical plan.  They are just a few words, but they pack a lot of meaning.

A major medical plan is a necessity in that it covers serious illness or injury—events with high costs. Under your major medical plan you will find coverage for hospital stays, medications and physician benefits. But the benefit is provided in different ways.

An indemnity plan has a deductible. That is the flat fee you pay before the insurance company’s coverage kicks in.  Once your covered expenses go over the deductible amount your benefits are usually paid as a percentage of the bill. Usually,reimbursement is at 80 percent of the bill. For the most part, you can choose which doctor and where you get treatment, so it is the most flexible.

What is a PPO?

As you look around for New York health insurance, you may have seen reference to a PPO plan—a preferred provider organization plan.  It is a major medical plan where you are given the opportunity to choose hospitals and doctors on a network list. Insurers have negotiated lower rates with these health care providers, so they’d like you to stick to the list.  You may be able to get treatment outside of their network, but you will usually have to pay a higher co-payment or deductible.

An HMO is different

In an HMO or health maintenance organization, you must get care within their network. You will choose a primary care physician from their list and that doctor will quarterback all of your health care.  If you need a specialist, your primary care physician may have to refer you, even if it is within their network.  If you want your claim paid through the HMO you must get treatment within the network. Out of network treatment is normally not covered or if it is covered, it is at a far lower rate.

A point of service or POS plan is a mix of the PPO and HMO.  While they are more adaptable than an HMO, you still have to choose a primary care physician. You can go outside of the network for service(for a higher co-pay), but if the primary care doctor refers you to an out of network doctor, the health plan will cover the cost.

We hope this helps you better understand some of your options when you compare New York health insurance.


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