Coverage underwritten on members of a natural group, such as employees of a particular business, union, association, or employer group. Each employee is entitled to benefits for hospital room and board, surgeon and physician fees, and miscellaneous medical expenses. There is a deductible and a Coinsurance requirement each employee must pay.
There are four fully-funded Medical Plans available and one Level Funded option:
PPO - Preferred Provider Organization
You are allowed to self-refer to any provider in the network. When using the in-network providers, the higher level benefit is received. This may be as much as 90% after the deductible. The benefit level for providers out of the network is typically 70% to 80%. Pre-authorization requirements must be met in or out of network. Providers in and out of network usually have a Doctor Office Copay.
POS - Point of Service
Very similar to an HMO in-network plan. It uses a "gatekeeper" (Primary Care Physician or PCP) to refer cases to other in-network providers. Deductibles usually only apply to out-of-network care. Co-insurance is either 90% or 100% for in network providers. Services received out-of-network are typically paid at the 60% to 70% level. There are exceptions...typical an emergency while away from network providers or treatment required from specialists not available in-network.
HMO - Health Maintenance Organization
The HMO uses a Primary Care Physician to direct all health care. No benefits are available outside of the provider network except when there is an emergency. HMO plans focus on wellness and preventive medicine and is the highest level of managed care.
Indemnity Traditional Coverage
The insured individual is free to use the doctor, clinic, or hospital of their choice. Both a deductible and a co-insurance apply and there are normally no co-pays for doctor office visits.
Level funding offers the same coverage and protection as fully-funded insurance plans, with the opportunity to get a refund on any un-used claims dollars. How does that work? The same as fully-funded insurance plans – a large portion of your premium dollars are put into reserves to pay claims. With level-funding plans, if your group has a healthy year they keep the claims dollars at the end of the contract term. Level-funded can be coupled with a PPO, POS, and HMO service platforms.