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Health Plans

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CheckPoint: Features of Health Plans
Tina M. Summerell
HCR/220 Claims Preparation I: Clean Bills of Health
December 2, 2011
Linda Johnson In health care plans, each type of plan has unique differences. Each plan is designed specifically for the type of health care plan and its coverage options.

One plan gives the choice when enrolled in a PPO of being able to refer oneself to a specialist in any field without the need for approval. This is, of course, providing the specialist is in the network of providers that are listed in the PPO plan, and the co-payment will not change. There is significantly less paperwork and the out-of-pocket expense is also less when one stays within the network. A PPO may not cover some preventative care services. Fee-for-services or differences in indemnity plans frequently include a cap for out-of-pocket expenses incurred; the insurance company will cover 100% after this cap is met. The cap for out-of-pocket expenses can be quite high which is not unusual and this plan has some similarities. One plan has absolute independence when it comes to choosing hospitals, physicians and other types of healthcare providers. One plan may consult with any physician of any specialty without having to obtain permission, and without the insurance company having the option to decide if the visit was needed. PPOs and point-of-service plans are comparable, unlike but PPOs, one will have to choose a primary care physician as a member of a point-of-service plan. One will need to select his or her PCP from a list of physicians within the plan’s network.

Much like the PPO, a member of a point-of-service plan can make the choice to seek treatment from a physician who is out of network and still obtain some type of coverage. One must customarily obtain a referral from his or her PCP before seeking treatment from a specialist. The option to refer

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