Types of Insurance

Familiarize yourself with the various types of insurance plans. Each type has different structures and rules which impact how services are covered and billed.

Types of Insurance

  • HMOs (Health Maintenance Organizations): Require members to get healthcare services from a network of designated providers and usually need a referral from a primary care doctor to see a specialist.
  • PPOs (Preferred Provider Organizations): Offer more flexibility by allowing members to see any healthcare provider, but provide better coverage for services received from in-network providers.
  • Point-of-Service (POS): You pay less if you use doctors, hospitals, and other providers that belong to the plan’s network. You’re required to get referrals from your primary care doctor to go to specialists.
  • EPOs (Exclusive Provider Organizations): Combine features of HMOs and PPOs, where members must use network providers except in emergencies, but don’t usually need referrals.
  • Medicare: A federal program for people aged 65 and older, and some younger people with disabilities. It includes different parts covering hospital services (Part A), medical services (Part B), and prescription drugs (Part D). https://www.medicare.gov
  • Medicaid: A joint federal and state program providing coverage for low-income individuals and families, with specific eligibility and benefits varying by state. https://www.medicaid.gov
  • Private Insurance: Health insurance plans provided through employers or purchased individually, offering a wide range of coverage options and flexibility.

Understanding Types of Health Insurance

Before you can start accepting insurance payments, it’s important to understand the different types of health insurance. Here’s a breakdown:

Types of Health Insurance

  1. Private Health Insurance:
    • Examples: Aetna, Blue Cross Blue Shield, UnitedHealthcare.
    • Description: Offered by private companies, usually through employers, individual plans, or through the Health Insurance Marketplace.
  2. Public Health Insurance:
    • Medicare:
      • Description: A federal program for people 65 and older and some younger people with disabilities.
      • Parts:
        • Part A: Hospital insurance.
        • Part B: Medical insurance.
        • Part C (Medicare Advantage): Offered by private companies, includes Part A and B, often Part D.
        • Part D: Prescription drug coverage.
    • Medicaid:
      • Description: A state and federal program that provides health coverage for low-income individuals and families.
    • CHIP (Children’s Health Insurance Program):
      • Description: Provides low-cost health coverage to children in families that earn too much to qualify for Medicaid.
  3. Managed Care Plans:
    • HMO (Health Maintenance Organization):
      • Description: Requires members to get healthcare services from a network of providers, usually needs a referral from a primary care doctor to see a specialist.
    • PPO (Preferred Provider Organization):
      • Description: Offers more flexibility in choosing doctors and hospitals; higher out-of-pocket costs for out-of-network services.
    • EPO (Exclusive Provider Organization):
      • Description: Requires members to use the plan’s network of providers except in emergencies; no referrals needed for specialists.
    • POS (Point of Service):
      • Description: Combines features of HMO and PPO; requires a primary care doctor and referrals, but allows out-of-network services at higher costs.
  4. High-Deductible Health Plans (HDHPs):
    • Description: Lower premiums but higher deductibles; often paired with Health Savings Accounts (HSAs).
  5. Short-Term Health Insurance:
    • Description: Provides temporary coverage for gaps in insurance.
  6. Catastrophic Health Insurance:
    • Description: Designed for emergency situations; high deductibles and low premiums; usually for people under 30 or with hardship exemptions.

Health Insurance Plan & Network Types: https://www.healthcare.gov/choose-a-plan/plan-types

Deciding Which Insurance to Accept As A Private Practice

Research and Considerations:

  • Patient Demographics: Understand the insurance coverage of your existing and potential patients.
  • Reimbursement Rates: Compare the reimbursement rates of different insurance providers.
  • Administrative Load: Consider the administrative effort required to work with each type of insurance.
  • Contract Requirements: Review the terms and conditions of contracts with insurance providers.

We suggest contracting with 3 major insurance companies in your state and Medicare. This is more than enough work to start with, then you can expand from there!

Continue Learning

Continue learning about insurance reimbursement best practices, growing your medical private practice revenue, researching ICD 10 codes, and much more:

Types of Insurance

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All content contains personal experiences and is not intended to provide medical advice. For personalized medical guidance, please consult with a qualified healthcare professional. The author and associated entities assume no liability for actions taken based on the content herein.