Buying Individual Health Insurance – HMO and PPO

If you are considering buying individual health insurance, HMO and PPO are two things that you should research about before shopping around for it. These two have very important differences, but they also provide almost the same services, and both focus on health insurance. HMO and PPO will most likely be terms that you will come across when you look around and are in the market for individual health insurance, and knowing the difference between the two will be useful and will be a great factor in choosing the right type of insurance for you when you hit the market for health insurance.

So what are HMO and PPO? We will start with the former. HMO stands for Health Maintenance Organization. A health maintenance organization will require you to choose a primary health care provider. In other words, you will have to choose which doctor you prefer because that doctor will be the only one you can go to and avail of your health insurance at the same time. This will mostly be determined by your doctor, if you have a specific go-to one, and if they are signed up to an HMO instead of a PPO. HMO is ideal for those who see specialist doctors or general practitioners, as most of them are signed up to an HMO contract.

PPO, on the other hand, if you are considering buying individual health insurance under a PPO, it will cover a wider range of health care provider services. As opposed to HMO, PPO will not restrict you to a primary health care provider. As long as the doctor is signed up to a PPO contract, you can avail of this doctor’s health care services. PPO, or Preferred Provider Organization, also offers a wider range of health care services that HMO might not provide. On top of that, PPO as a third party organization makes health care providers charge at reduced rates to its clients.

HMO generally gets bad press for its restrictive rules and services provided. People buying individual health insurance opt for PPO instead of HMO. But PPO proves to be significantly more expensive despite its reduced rates, as it has a wider range of coverage for their clients. HMO is more for you if you need to see a doctor for only a certain amount of health care services, such as illnesses that are chronic and need regular check-ups and special services. PPO will prove more useful if you anticipate emergencies instead of regular doctor visits, and will offer more flexibility in its coverage than HMO can offer.

In the end, choosing individual insurance would depend solely upon your health care needs. Purchasing individual insurance will guarantee that you never get caught empty handed, but availing of the wrong type would still leave you with that problem, as HMO and PPO are two different contracts and your health care provider might be signed up to either one of these. Buying individual health insurance wisely by doing all the necessary research and knowing what its coverage is will prove to be very useful in cases when you need health care the most.

Guide to Individual Health Insurance

The new Covered California health insurance marketplace offers a wide range of affordable health plans for you to choose from. Whether you are self-employed, or looking for coverage over and above what your employer currently offers, there is a plan that will likely meet your needs. Federal regulations require that health plans operating under the Affordable Care Act (ACA) meet certain access requirements. In California, those requirements include timely access to healthcare providers, as well as geographic access standards.

Here is a general guide to individual health insurance that you can refer to when choosing a plan. And do not forget these important dates regarding open enrollment for 2016.

Provider Networks

When selecting a health insurance plan, it is important to verify the plan’s provider network of doctors, hospitals, nurse practitioners, therapists, and other health care providers. It is equally important to understand what is not covered as well. Understanding your plan’s provider network helps you save money, receive better care, avoid unexpected fees and costs, and be happier with the care you receive.

Out-of-Network Care

You are not restricted to health care providers in your network, but should you decide to use one outside of your network, health insurance will cover less resulting in a higher out-of-pocket cost for you, except in the case of emergencies.

Provider No Longer in Network

If your health care provider leaves your network, you will generally need to find a new doctor inside the network, and most plans will assist you in doing so. As a rule, a health plan’s continuity of care policy allows a patient to continue care with a doctor no longer in the network for a certain period of time at the lower cost-sharing rate.

Cost-Sharing Requirements

Each plan has different cost-sharing requirements. Typically, your overall share of costs is a combination of the premiums you pay plus any other co-payments, co-insurance or deductibles for which you are financially responsible.

How to Find a Doctor

In most cases, the plan you choose will have a list of doctors who accept your insurance. The Medical Board of California offers some great tips on choosing a doctor:

  • Ask friends, family or co-workers about physicians they like.
  • Ask your county medical society or association for names of physicians in your area.
  • Once you have some names, call and ask if the doctor is accepting new patients and whether they accept your insurance plan.
  • Check with the Medical Board to verify the physician has a current California license.
  • Meet with the physician and consider having a physical done to determine if this is the doctor for you and your family.

Selecting a Hospital

When you undergo treatment in a hospital or other facility, ask to have any services performed by in-network providers. Your physician may decide which hospital is appropriate for your care, but you can still check the hospital’s California HealthCare Foundation rating by visiting

This guide to individual health insurance is far from complete. For more information and a more comprehensive glossary of insurance terms and other marketplace information, visit

Learn More

From preventative services to out-of-pocket maximums, understanding your individual health insurance plan options can be a confusing – and frustrating – endeavor. A health insurance agent is one of your best resources for information on coverage that meets your unique needs.

5 Keys to Choosing the Right Individual Health Insurance Plan

The internet has made it easier to compare different health insurance policies and shortlist health insurance plans. With the right health insurance policy, one can make substantial savings if a family member gets sick. Although there is no golden rule to choose the right individual plan, yet, some common tips help in the decision making process. Five keys to choosing the right individual insurance plan have been listed below:

• Determine your need and your affordability: Even before you start your online search for insurance plans, one needs to be sure about the details of the plan. You need to make sure that the benefits offered by the plan covers what you need for yourself and your family. However, the perfect plan will also come at a considerable cost. As an informed customer, you need to do a proper cost benefit analysis to make sure your trade-off between price and benefit is in the appropriate proportion. If we take into account, frequent trips to the doctors, medications and dental coverage – such scenarios eliminate unsuitable plans and makes the comparison process much easier.

• Don’t overbuy: The scenario is similar to buying a luxury car where the monthly EMI equals your home loan payment. There is no point in purchasing a health insurance policy with benefits which are unlikely to be used at a high and unviable cost. For relatively young and healthy individuals, a policy with a high deductible is more suitable. Deductibles are the amount paid by insurers before certain benefits kick in. A plan with a decent deductible will cost considerably less per month and could save money in the long run.

• Walk through several plans: It is always advisable to go through several plans. In the process, benefits associated with different health insurance plans can be reviewed and analyzed for better decision making. At first glance, some plans may look appealing. Later, the same plan turns out to be a costly affair due to cost sharing arrangement. The burden of medical cost in the future will be a big headache. Hence, going through and analyzing several plans is the best way forward.

• Co-insurance and co-payments: Several health insurance plans require the holder to contribute to the coverage payments. The contribution is called co-insurance and is the portion the customer has to pay after deductible. A co-pay is a flat fee one has to pay while paying a visit to a doctor or specialist. While choosing a personal health insurance policy, consumers should look into co-insurance and co-payments factors.

• Reputation matters: After identifying the price and need of the plan, reputation of the company should also be in the reckoning. Ideally, a company with a long haul in the market should be trusted and relied upon. There are many ways to assess the standing of insurance companies and their health insurance policies.