Individual & Family Insurance

Each carrier has different underwriting guidelines in place that determine the “risk” an individual presents. There are four possible outcomes of pre-existing conditions:

• A temporary exclusion rider – The insurance carrier will insure you, but will include a clause that excludes the pre-existing condition/medication for a certain amount of time.
• A permanent exclusion rider –The insurance carrier will insure you, but will include a clause that excludes the pre-existing condition/medication indefinitely.
• Rated-up premium – The insurance carrier will cover you and the pre-existing condition/medication, but will require additional premium every month.
• Decline – The insurance carrier declares you uninsurable and, therefore, will not extend an offer to insure you.

• Health Maintenance Organization (HMO) – HMO plans provide services to members through a network of HMO providers.  The individual and his family members select a Primary Care Physician to provide their medical care and refer them to a specialist, if needed.  With the exception of emergency care, or prior approval, only services provided in-network will be covered under an HMO.  HMO plans are also known for their emphasis on preventive care and wellness initiatives.
• Point-of-Service (POS) – POS plans have in-network and out-of-network coverage.  Under a POS plan, you have the option of seeing your primary care physician (PCP) (in-network) or choosing to be treated by another provider (out-of-network).  Benefits will still be available to you if you choose an out-of-network physician, but the cost will be greater to the member.  POS plans are either open access, meaning you do not need a referral from your PCP, or they require a gate-keeper, meaning you must see your PCP in order to get a referral to specialists.  POS plans work similarly to a PPO plan, but generally at a fraction of the cost.
• Preferred Provider Organization (PPO) – Like POS plans, PPO plans have in-network and out-of-network coverage.  You will still receive benefits by going out-of-network, but the cost to the member will be greater.  The most notable difference between PPO and POS plans is the provider network. The larger network is generally found with PPO plans.
• Health Savings Account (HSA) – Perhaps one of the best financial approaches to health care is the High Deductible Health Plan (HDHP) with a Health Savings Account (HSA).  These plans fit perfectly for those financial savvy individuals who have an established emergency fund and who view health insurance as a product to protect against “catastrophic” health care costs. These plans allow individuals to establish and contribute to a tax-free HSA which may be used to cover medical expenses you incur while unused funds remain available for future years.  While HSAs are not right in every instance, they should be considered in your health insurance evaluation.