Medical Insurance - Health Insurance Coverage & Plans Explained

For many years people felt that they were trapped between a traditional indemnity health insurance plan (a wide range of choice and high degree of security in the event of serious accident or illness which came at a high cost) and a managed care plan (a focus on preventative medicine at relatively low cost but with severely limited choice).

Today however it is possible to some extent to enjoy the benefits of both traditional indemnity insurance and managed health care through a variation on the original Health Maintenance Organization (HMO) model known as a Preferred Provider Organization (PPO).

A PPO is essentially an HMO which means that the insurance company will establish a network of healthcare providers and, in exchange for a relatively low cost, will encourage, or in some cases require, policyholders to seek treatment within the HMO's network. Where treatment is taken outside of the HMO's network much, if not all, of the cost of such treatment normally has to be borne by the policyholder. However, in the case of a PPO, the rules for policyholders who wish to seek care outside of the HMO's network are relaxed.

Within an HMO a policyholder is assigned to a particular doctor or primary care physician (often referred to as a "gatekeeper") and the policyholder must go through the primary care physician in order to receive treatment. If, for example, the policyholder wishes to see a specialist then he or she will have to be referred by the primary care physician and may or may not have a say in which particular specialist they are referred to.

In a PPO however no primary care physician is assigned and so no referral is required. Policyholders are free therefore should they choose to do so to seek treatment through a specialist who is not a member of the HMO's network.

There are of course cost implications to this choice and policyholders will almost certainly have to pay more for treatment with a doctor or in a facility that is outside of the HMO's network than they would if they sought treatment within the network. Nevertheless, unlike the HMO model, the PPO gives the policyholder the choice.

If you like, a PPO provides policyholders with the low cost managed health benefits of the HMO with the option to elect for the greater choice, albeit higher cost, of indemnity insurance when it suits their needs.

It will probably come as no surprise to find that today traditional indemnity policies are fast disappearing and that there are now twice as many people enrolled in PPOs as there are in HMOs.