Health Insurance 101
Everything you wanted to know about health
insurance but were afraid to ask!

Q: What is the difference between an HMO and a PPO?

A: An HMO or Health Maintenance Organization is a form of managed care where doctors, hospitals and other care givers are contracted to take care of you for a fixed monthly fee. Most HMO's involve you choosing a primary care physician or PCP who acts as the gatekeeper for your medical needs. You see the PCP first who may refer you if needed to a network specialist. HMO's usually include a pharmacy benefit and a copay amount for each doctor or hospital visit, but no deductible amount. A recent addition to many plans allows you to self direct to a doctor on the plan. Quest Health Plans represents all of the major HMO plans in Colorado and can find the most cost effective solution to your choice of HMO provider. A PPO or Preferred Provider Organization differs from an HMO in that there is no PCP or gatekeeper. You usually direct yourself to a physician or specialist as long as they are in the network. In return for this added freedom you will have an annual deductible amount and a co-insurance amount which must be satisfied before the insurance pays the balance of a claim. For example, a PPO with a $500 deductible and 80/20% to $5,000 means you will pay the first $500 of eligible claims and 20% of the next $5,000 in claims or $1,000. Therefore your total out of pocket expense for the year will be $500 plus $1,000 or $1,500. Usually two or three deductibles must be satisfied for a family. A recent twist to the PPO marketplace are plans which allow a doctors visit for a fixed amount (say $10-$30) and certain other allowances for lab tests and x-rays without going into the deductible. Quest represents all of the major PPO providers in Colorado and can explain the differences between and within each of the plans.

Q: What is the difference between group coverage and individual coverage?

A: Individual coverage, whether for you alone or with a spouse or children is medically underwritten. This means that if you have a serious medical problem or condition or take certain drugs you may not be accepted. The application includes a medical questionnaire. Individuals and families may apply for either HMO or PPO coverage. Group coverage is only available to companies or self employed individuals. Groups as small as 1, the employee only, can be arranged by Quest, but proof of being in business and other conditions must be met. The main advantage of group coverage is that no medical underwriting is required. Guaranteed issue means that anyone on a group plan must be covered, by law, no matter what medical condition is present. Groups may apply for HMO or PPO coverage. Call Quest to see if you qualify.