Health Ministry Page

March 2002

Defining Health Coverage by Type

	Indemnity Plan	PPO Preferred Provider Organization	POS Point of Service	HMO Health Maintenance Organization
Definition	Traditional insurance plan that reimburses a % of fees up to “reasonable & customary”.	Allows selection from a network of hospitals & doctors for highest benefit coverage; you pay greater % for non-network providers. No PCP (primary care physician)	Similar to PPO but all care must be provided by or directed by a PCP for highest benefits coverage.	All benefits provided by select network of doctors & hospital: PCP must provide or direct all health-care services; no coverage for non-network providers.
Freedom to Choose	You receive benefits for care from any doctor or hospital.	Benefits are better if you use a participating PPO provider.	Benefits are better if care is provided or directed by your PCP.	Benefits only for care received from HMO participating providers, as long as referred by PCP.
Primary Care Physician (PCP)	No PCP required.	Not required to consult a PCP to receive covered care.	Required to consult a PCP for care or referral for specialized care.	PCP monitors all services and directs referrals to specialists.
Reimbursement	Traditional plan with annual deductible before plan pays share (usually 80%) for eligible costs.	Usually small co-pay; annual deductible. Pays share for other services; higher benefits when service from PPO network.	Usually small co-pay; annual deductible & separate hospital deductible; higher benefits from PPO network.	Usually no deductible; small co-pay; may be separate hospital co-pay. NO benefit for services without PCP referral. Your costs generally lower.
Other Features	*Most services covered; often requires pre-certification of hospital stays / surgery. *Generally no benefits for preventive care. *Select physician / specialist freely for needed care.	*Most services covered, often pre-certification required but done by provider. *May include some preventive care. *Select physician / specialist freely.	*Most services covered; pre-certification & referrals done by provider. *Preventive care usually included. *Usually select PCP when you enroll.	*Most services covered; pre-certification by provider. *Includes preventive care & office visits. *Usually select PCP on enrollment.