A Guide to Health Insurance Plans for Doctors

For most doctors, they are not intimately involved with the nuances of health insurance plans. Usually, if it is something handled by the front office team as a part of the patient intake process.

However, there will be times when it is valuable for doctors to know the differences in the types of health insurance plans. and how each affects the way they get paid.

With this in mind, here is a brief guide to each type of healthcare insurance plans for doctors.

FSA (Flexible Spending Account)

HSA (Health Spending Account or Health Savings Account), or even an HRA (Health Reimbursement Account)

A FSA plan lets patients use pre-tax dollars to pay for their eligible health care expenses for themselves, their spouse, and their eligible dependents.

Money is set aside from the patient’s paycheck before taxes are taken out. They can then use the pre-tax FSA dollars to pay for eligible health care expenses throughout the plan year. In this way, they save money doctors’ office visits, prescription drugs, and other healthcare items.

Health Maintenance Organizations (HMOs)

The HMO delivers all health services through a network of healthcare providers and facilities. With an HMO plan, your patients have less freedom to choose health care providers, and the least amount of paperwork compared to other plans.

As a primary care doctor, you are able to manage your patients care and refer them to specialists when they need one. Most of your HMO patients will require a referral before they can see a specialist.

Preferred Provider Organizations (PPOs)

The PPO delivers health services through a selected network of healthcare providers and facilities. With a PPO plan, your patients have a moderate amount of freedom to choose health care providers, typically more than HMO patients.Often they do not have to get a referral from their primary care doctor to see a specialist.

PPO patients have higher out-of-pocket costs if they see out-of-network doctors vs. in-network providers. They may also have more paperwork than with other plans.

Exclusive Provider Organizations (EPOs)

A EPO healthcare plan combines the flexibility of PPOs with the cost-savings of HMOs. Your patients won’t need to choose a primary care physician, and they don’t need referrals to see a specialist. However, they will have a limited network of doctors and hospitals to choose from.

This plan can offer your patients a moderate amount of freedom to choose you as their health care provider – typically more than an HMO. However, they may have no coverage for out-of-network providers. So if they see a provider that is not in their plan’s network they will have to pay the full cost of the visit.

Point-of-service (POS) plans

A POS plan blends features of an HMO with a PPO. With POS plan, your patients may have more freedom to choose your health care providers than you would in an HMO, and a moderate amount of paperwork if they see out-of-network providers. They will usually have a  primary care doctor who coordinates care and refers them to specialists

High-Deductible Health Plans (HDHPs)

Similar to a Catastrophic plan, patients may be able to pay less for insurance with a high-deductible health plan (HDHP). With an HDHP, your patients may have higher out-of-pocket costs than many types of plans.

Like other plans, if they reach the maximum out-of-pocket amount, the plan pays 100% of their care. A health savings account (HSA) may also help pay for their care. This is because, in order to have a HSA, patients must be enrolled in a HDHP.

Many bronze plans may qualify as HDHPs depending on the deductible (see below).

The Difference between Platinum, Gold, Silver Bronze and Catastrophic Plans

If a patient purchases a healthcare plan from a marketplace, they will typically be tiered in a system of Platinum, Gold, Silver, Bronze or Catastrophic. Here is a breakdown of the benefits of each for your patients:

Platinum: typically covers 90% on average of medical costs and the patient pays 10%

Gold: typically covers 80% on average of your medical costs and the patient pays 20%

Silver: typically covers 70% on average of your medical costs and the patient pays 30%

Bronze: typically covers 60% on average of your medical costs and the patient pays 40%

Catastrophic: Catastrophic policies typically pay less than 60% of the total average cost of care. If the patient is under 30, they may also be able to buy a high-deductible, catastrophic plan. Catastrophic plans must cover the first three primary care visits and preventive care for free, even if the patient has not met their deductible.