Types of Insurance Policies
When it comes to health insurance plans there is no 'one-size-fits-all' category. Different plans offer different benefits, such as the freedom to choose a specialist without a referral or cost-savings for using a plan that requires you to choose a primary care physician to oversee all of your medical care.
Knowing what the different plans are – and the different advantages they offer – can help you choose a plan that meets your specific needs.
Protect your most precious valuables — your kids!
That's exactly what a health insurance policy is supposed to do. But sometimes you get an unexpected bill because your policy didn't cover a procedure, doctor or hospital stay. If you have an appointment, visit to the hospital or a procedure scheduled, know before you go.
PPO (Preferred Provider Organization)
PPO plans contract with doctors and hospitals to provide services at reduced costs. These are considered in-network health care providers. Members are able to see doctors and specialists within the network without a referral. When you use in-network medical providers, the plan typically pays most of the cost of treatment. However, members of PPO plans will pay out-of-pocket costs, such as copays and deductibles. PPO plan members can also use out-of-network health care providers, but will have to pay higher deductibles and copays.
HMO (Health Maintenance Organization)
HMO plans typically enable members to have lower out-of-pocket health care expenses and may also offer less flexibility since members must use the services of participating doctors, hospitals and clinics in order to have their care covered by their HMO plan. Members are required to choose a primary care physician (PCP). PCPs will take care of most of the health care needs. Before members can see a specialist, a referral must be obtained from the PCP. Members do not usually have deductibles or copays. There is no coverage for services rendered by non-network providers or for services rendered without a proper referral from the PCP. HMO plans may also be referred to as PCP Referral Plans, which function as an HMO.
POS (Point-of-Service plan)
POS plans combine some of the features offered by HMO and PPO plans. Members often enjoy more cost savings than a PPO with more flexibility than an HMO. As with an HMO, members of a POS plan may be required to choose a primary care physician (PCP) from the plan's network of providers. Members may also need a referral to see a specialist, but unlike an HMO, patients can often go out-of-network to see a specialist or access medical services. Some services rendered may have higher out-of-pocket costs than others and members have more of the flexibility of a PPO. Overall, premiums for a POS plan tend to be 50 percent less than a PPO plan, but 50 percent more than an HMO.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time. These extensions offered under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost of the plan. COBRA generally requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end. During the COBRA period, the benefits remain the same as the employer's group plan.
Also referred to as a fee-for-service plan, a traditional Indemnity plan offers a great deal of freedom in choosing which doctors and hospitals to use, but usually involve higher out-of-pocket costs. Under an Indemnity plan, members may see doctors or specialists of their choosing, with no referrals required. Depending on the type of indemnity plan offered, members may be required to pay for a service in full then file a reimbursement claim to their health insurance plan. In addition, many indemnity plans require the members meet an annual deductible amount before any amounts are paid on claims. Amounts paid on claims are often at a specified percentage of the service fees/charges based on the average rate for those services in the member's or medical provider's area.
Health Care Exchange
As part of the Affordable Care Act (ACA), exchange plans allow individuals to shop for affordable health insurance options in their state, compare the plans available to them and purchase/enroll in a health plan. Applicants can shop for Texas exchange plans on HealthCare.gov. Exchange plans offer coverage from private insurance companies that provide essential health benefits. Each plan offers different levels of flexibility in terms of in-network and out-of-network services, so participants should check to see if their current providers are contracted with a particular plan before enrolling. Plans also offer different levels of deductibles and copay, often at lower out-of-pocket costs and monthly premiums than non-exchange private insurance.
Health exchanges in the state of Texas
Each state approved specific companies to sell plans on the exchanges. Coverage options vary greatly depending on the providers your state selected. Several of the health exchange plans provided by the state of Texas do not contract with many hospitals, including pediatric hospitals, such as Cook Children's. It's important that you confirm that your child's preferred providers are in-network BEFORE choosing a new plan on the exchange. Additionally, a good number of the insurance plans have limited or no out-of-network benefits, meaning you will be financially responsible for all unpaid charges if you visit a service provider not on the plan. To ensure that your child's plan includes Cook Children's as a health care provider so that you and your family do not incur any unexpected out-of-pocket expenses for your child's care you will want to choose an exchange plan that includes Cook Children's as a provider. To learn more about which of the exchange plans with which Cook Children's has a contract as an in-network provider, click here.
Physician only networks
These plans only offer a network of contracted physicians. These plans may offer benefits for hospital services, but do not offer contracted hospitals to provide services to the insurance plan's members at a discounted rate. Non-contracted providers reserve the right to not accept the plan benefits.
Limited medical benefits
A limited medical benefit plan is not meant to replace a comprehensive medical plan. This type of plan covers a minimal established amount for health care services or may not cover certain medical services at all. These plans often use a PPO Network to allow the insurance plan's members to receive a discounted rate on their patient portion due. The member is responsible in full for any remaining charges after the minimal payer payment. The member is responsible in full for any non-covered services. These plans typically have high deductibles and a very low dollar limit on annual coverage.
People under 30 and people with hardship exemptions may buy a "catastrophic" health plan. This type of plan mainly protects you from very high medical costs. It is protection from worst-case scenarios.
A catastrophic plan generally requires you to pay all of your medical costs up to a certain amount, usually several thousand dollars. Some care is paid for before you reach this limit, known as a deductible. After you reach your deductible, costs for essential health benefits are generally paid by the plan.
Catastrophic plans usually have lower monthly premiums than comprehensive plans, but cover you only if you need a lot of care. They basically protect you from worst-case scenarios, like serious accidents or illnesses. Catastrophic plans cover prevention and some primary care.
In the Marketplace, catastrophic plans cover three primary care visits per year at no cost, even before you've met your deductible. They also cover free preventive services.
If you buy a catastrophic plan in the Marketplace, you can't get lower out-of-pocket costs based on your income. Regardless of your income, you pay the standard price for the catastrophic plan.
Do you qualify for a catastrophic plan in the Marketplace?
When you fill out a Marketplace application you'll see catastrophic plans listed as options if you qualify for them either by age or because you have a hardship exemption. If you don't qualify for a catastrophic plan, you won't see them as an option.
Medicaid and Children's Health Insurance Program
Children in low-income families may receive health care coverage through the Children's Medicaid program or the Children's Health Insurance Program (CHIP). Both programs provide a wide range of benefits, including doctor's visits, immunizations, prescription drugs, dental, vision and behavioral health and hospital services. There is one application for both programs. In Texas, applications for Medicaid and CHIP are reviewed by members of the Health and Human Services Commission (HHSC) to determine if a child is eligible for either Children's Medicaid or CHIP.
MCO (Managed Care Organziation)
Managed Care Organization (MCO) are also referred to as Star plans. Medicaid requires most members to select a Star plan and primary care physician (PCP) during enrollment. If the member does not select a plan or a PCP, Medicaid will automatically assign the member a local provider and enroll the member in one of the available plans in the service area where you live.
Medicare provides health insurance for people 65 or older, people under 65 with certain disabilities and people of any age with end-stage renal disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant). Medicare has different parts of coverage for health care services.
TRICARE is a health care program of the United States Department of Defense Military Health System. TRICARE provides civilian health benefits for military personnel, military retirees and their dependents, including some members of the Reserves. TRICARE Prime is a managed care option with an assigned primary care manager (PCM) who provides most of your care and obtains referrals for specialty care. Members must use network providers. If using non-network providers, members must have an authorized referral in place prior to accessing care. TRICARE Standard is a fee-for-service plan available to all beneficiaries (except active duty service members). Members may visit a non-network provider using the Standard option and will pay higher cost shares. Members may visit a network provider using the Extra option and will pay lower cost shares. Referrals are not required, but members may need preauthorization for some services.
Financial assistance and charity care
Part of Cook Children's Promise is to serve the health care needs of every child in our community. Sometimes this means lending a helping hand by providing charity care or financial assistance to eligible needy patients. The key qualifications for charity care and/or financial assistance include children who:
- Are classified as financially, medically or catastrophically indigent;
- Have applied for Medicaid and complied with applicable Medicaid requirements when Medicaid eligibility is a possibility; and
- Have been denied financial assistance (e.g., Medicaid, Children's Health Insurance Program (CHIP), Children with Special Health Care Needs (CSHCN), Supplemental Security Income (SSI) or other government-funded programs) from their service area.
These financial options are available to children who are admitted to Cook Children's Medical Center on an emergency basis and do not have the resources to pay for the services. We may also assist families whose children are in current treatment and require financial assistance with other aspects of a child's care which might include such things as lodging, transportation, etc. This is done on a case-by-case basis and only after all other sources of assistance have been explored and/or exhausted. All charity or financial assistance will be granted, if qualified, without regard to gender, race, creed, color or national origin. Our primary goal is care for the child.
Cook Children's is not an authorized provider, nor do we accept Care Credit.