1. Group HMO Plans- Generally:
|HMO Plans require the member to use the providers (physicians,
hospitals, pharmacies, other ancillary providers) in the HMO’s contracted
network. The member is required to select a Primary Care Physician
(PCP), who provides the member with referrals to network specialists.
There are no out-of-network benefits, except in the case of emergencies.
HMO plans typically use a co-pay structure, with the member paying a set
amount to the provider (i.e. $10.). Group HMO Plans can be priced on a
composite or average rate (cost) per employee.
2. Group PPO Plans- Generally:
PPO Plans require the member to use the providers in the PPO’s
contracted network. However, PPO Plans do not require the selection of
a PCP and typically offer out-of-network benefits at a reduced level.
PPO Plans are structured with a deductible and co-insurance, paying
benefits at a set % of the total bill (after the deductible), with the member
assuming responsibility for the balance (i.e. $500. deductible; 80%/20%
plan). Group PPO Plans can be priced on a composite or average rate
(cost) per employee.
3. Group POS Plans- Generally:
These plans are typically structured as HMO/POS plans where the
member can stay in-network using the HMO co-pay structure, or can use
an out-of-network provider, under the POS structure, with reduced
benefits (like that of a PPO).
4. Self-Funded Plans- Generally:
These plans are typically best suited to larger employer groups. The
employer group selects a Third Party Administrator (TPA), to administer
the group’s plan and funds its own employee health benefits, under a
selected plan design (i.e. a PPO Plan design), and using a contracted
provider network (i.e. a PPO Provider Network). Self-Funded employer
groups sometimes purchase Stop-Loss Insurance to limit their exposure
beyond a pre-determined level.
5. Limited Coverage Plans- Generally:
There are limited coverage plans available to groups. However, these
are usually limited to groups with a minimum number of employees
(varies). These plans typically offer limited benefits and require the use
of the providers in their contracted network.