Knowledge Center

• Suitable for young and healthy individuals who visit doctors infrequently. Also suitable for people who do not prefer the referral process.
• No referral necessary. You may visit any participating providers directly.
• Freedom in choosing from plenty of providers. Convenient to use.
• Member must pay copayment or coinsurance for part of the medical expense, e.g. 30% of hospital inpatient expense or lab fees.

• Suitable for individuals who have chronic disease, frequent doctor visit needs, and medication needs. Also suitable for people who plan to get pregnant and expect to conduct surgery.
• Applicant must designate a family doctor and the doctor’s related medical group. If family doctor and medical group are not indicated, then the HMO would select one for the applicant. Unless you are under treatment or pregnant, you may change your family doctor and/or the doctor’s related medical group anytime, which will generally become effective on the first of the following month.
• Family doctors include Internal Medicine Doctors, General Practice Doctors, Family Practice Doctors, and Pediatricians.
• One of the disadvantages of HMO is its referral process. If the family doctor refuses or postpones the referral, treatment may be delayed. However, you generally share a small amount of the medical expense, e.g. $0 copay for hospital inpatient expense.

POS is a combination of PPO and HMO, which gives you flexibility in meeting your medical needs. If your doctor or hospital is within your designated medical group, then you may use the HMO side of your plan. Hence, your share of the medical expense is small. On the other hand, if your doctor or hospital is not within your designated medical group, you may use the PPO side of your plan. Although your share of the medical expense will be relatively higher, insurance carrier is still paying part of the expense for you. Since POS includes the benefits of PPO and HMO, its monthly premium is generally higher than PPO and HMO plan alone.

Some health plans have an annual deductible. It is the amount you must satisfy in a year before benefits are available to you. Most PPO plans have annual deductible, and most HMO plans do not have annual deductible unless otherwise indicated. Medical and prescription deductibles are generally separated.

In order to lower medical expense, insurance carriers have negotiated a reasonable rate with the participating providers for each individual medical service, which is known as the negotiated fee. When participating providers charge a fee in excess of the negotiated fee, you are not responsible for the excessive charge. However, if the providers are non-participating, then you are ultimately responsible for paying the excessive charge above the negotiated fee.

This is the amount or percentage you are responsible to pay for covered services. If it is a fixed amount, such as $40, it is known as Copayment. If it is a percentage value, like 30%, we call it coinsurance.

Each calendar year, the maximum amount you need to pay is known as the annual out-of-pocket maximum, which protects your share of medical expense to a fixed limit. However, out-of-pocket maximum excludes copays for doctor visits and prescriptions.

An insurance carrier will continue to cover medical expenses for each insured until a lifetime maximum is met. For example, a patient who has cancer requires continuous medical treatment. Unless the patient fails to pay premium on time, the insurance carrier will continue to pay for the covered expenses until the lifetime maximum is met. Lifetime maximum is usually $5,000,000 or $6,000,000.

If you or any applicant has pre-existing condition, insurance carrier would determine your eligibility based on the type and severity of the condition. Even if your application is approved, insurance carrier may impose up to a 6-month waiting period on your pre-existing condition, which means any medical expenses related to your pre-existing condition would not be covered during the initial 6 months.

If you rarely visit doctors or only visit doctors for preventive care, you may consider a type of PPO health plan that provides First Dollar Coverage. Since it is a PPO health plan, you do not need to designate a family doctor. You may visit any participating providers directly. Each year (or each season), the insurance carrier will fully cover your medical expenses until a fixed amount is used up. Medical expense usually includes office visits, preventive care, and lab fees. If your medical expense does not exceed the first dollar coverage, then you do not need to pay any copayment or coinsurance. For example, an insurance carrier gives you $250 first dollar coverage per season. If the cost of preventive care is $200, then your copayment or coinsurance for the service is $0. Insurance carrier will pay the entire $200 for you. On the other hand, if the preventive care costs $300, then insurance carrier will only pay up to $250. You will need to pay the remaining $50. Most First Dollar Coverage plans allow unused amounts to be rolled over to next year or season.

(Each insurance carrier offers different First Dollar Coverage. The above example is for reference only. Please read the details of each plan before purchasing coverage.)

• Minimum 2 employees
• Must have business license and appropriate state filings
• Most insurance carriers require applying groups to be in operation at least half quarter, or 7 weeks.
• At least 2 eligible employees must enroll in group health insurance. Most insurance carriers require a minimum of 75% participation from all eligible employees. If employer pays 100% of employee’s premium, some insurance carriers may require all eligible employees to be enrolled in the group health insurance. In addition, employers may choose to provide coverage for part-time employees as well.

Most insurance carriers require employers to contribute a minimum of 50% of employee’s health insurance premium. Of course, employers may choose to pay for 100% of the premium. Some insurance carriers allow employers to choose to contribute a fixed amount per month per employee, such as $100. Any excessive premium will be deducted from the employee’s payroll. In addition, employers may choose to pay for the premium for the employee’s dependents as well.

Employer may set a waiting period before a new employee can be eligible for group health insurance. Employer may choose from 1st of the month following hire date, or 1, 2, 3, 4, 5, or 6-month waiting period. A new employee is qualified for group health insurance on the 1st of the following month after satisfying the waiting period requirement.