What is private health insurance?

“Private insurance companies are the insurance programs that people get through their jobs, and these can vary massively in terms of what they cover and how they work,” Mintz said. “There’s also hospital or clinic-based insurance, where hospital systems offer specific insurance products that allow you to see doctors that are in their network of care. For everything else, you have to pay out of pocket.”

Employer Benefits

“If you receive health insurance through your employer, it’s important to look into the specifics of your plan. If you’ve never done this before, I would write down each thing you need: medications, specialists appointments, regular therapist appointments.

As you’re looking at plans — including looking at the plan from your employer — check what each specific thing will cost. I’ve had patients get health insurance through their employer, then go get routine labs and get hit with some part of their deductible thinking it was supposed to be paid for. 

It’s really important to do your best to try and think about this stuff before it happens rather than after. Specifically in our communities, it’s important to check if there are coverage exclusions around things.

Most workplaces offer either flexible spending accounts or health savings accounts. Usually, during an open enrollment period, you can choose to have some amount of money taken out of your check, tax free, to use to pay for healthcare and to pay for those uncompensated expenses. 

Different jobs have different policies about how it all works and what is covered, so you’ll need to look into what a flexible spending account covers. Does it only cover particular things? Do I need a letter from my doctor confirming [something I purchased] was a health care expense? There are different ways this type of health insurance is organized.”

Healthcare Management Account (HMO)

“A Healthcare Management Account (HMO) is a healthcare management plan, which means that the health insurance company says a certain group of doctors and clinicians are responsible for the entirety of your healthcare. 

On the hospital side of things, via the Affordable Care Act, there are similar programs where medical groups sign up to be paid instead of to be paid at once, instead of being paid for each thing individually. The medical providers are getting a chunk of money to take care of you and then they provide your care for the year.

Usually, HMOs restrict the number of people that you can see. If you think about it, none of this is for the benefit of the patient. The way most organizations and institutions are set up, it relies on a primary care doctor to act as a kind of quarterback for everything else. 

Usually, people can decide who they want as a primary care doctor, but often there are [stipulations]. You get a primary care doctor, then they can get you a referral if you need a referral somewhere else.”

Preferred Provider Organization (PPO)

“A Preferred Provider Organization (PPO) is a network where a certain group of healthcare providers have signed up to be accessible to provide your care. Usually, a PPO is way more flexible. 

A lot of times, an HMO, will be within one healthcare system or one environment, a PPO covers a bit more, covers more doctors and often — more so than an HMO — allows people to just access services, specialists and support on their own. 

If somebody needs a rheumatologist, they can call a rheumatologist, rather than needing a referral. [However,] in a lot of cases for a lot of places those differences have just been erased or mushed together. The important thing is to look at the specifics of the plan, especially for surgical planning.”