HEALTH INSURANCE Benefits offered by Sedona Benefits
Sedona Benefits offers a broad range of health plans, varying costs, levels of health coverage, and accessibility to health care. The following are important considerations for helping you identify which plan is right for you:
· Price — What are the monthly premiums for each plan? What can you afford?
· Features — What health care services does each program cover?
· Cost-sharing — What would be your share of the cost for these services?
· Access — Is it important to you to see any doctor you want or are you willing to trade that flexibility for some other benefit?
The plan type you choose will determine how you select and access health care services. The difference is in the deductibles, coinsurance amounts, and annual out-of-pocket maximums. Other differences include whether maternity is covered and what kind of prescription coverage, if any, is included. In general, the wider your choice of doctors and hospitals, the higher your costs will be in terms of premiums and/or levels of health care coverage.
What's the difference between a PPO and an HMO?
There are many differences between them, but the most significant difference is how you access care. If you're covered by a PPO plan, you may visit any licensed doctor. In an HMO plan, you need to access non-emergency care through a designated Personal Physician to be covered.
Health Maintenance Organization (HMO) Plans
HMO Plans provide extensive coverage with low out-of-pocket costs for covered health care services you received only from HMO Network doctors and hospitals.
- HMO Plans cover more of the costs of your health care than any other plan type.
- HMO Plans provide coverage only for services received from doctors and hospitals within the HMO Network.
- You choose a specific health care group and physician within the network to coordinate all of your health care needs or one can be assigned for you.
Preferred Provider Organization (PPO) Plans
The PPO Plans offer you the most flexibility in your choice of doctors and hospitals (providers). PPO Plans provide coverage (at different levels) for services from both Participating and Non-Participating Providers. The insurance company negotiates discounts for you when you use a doctor or facility in their network. By using a participating doctor, your costs will be substantially lower and you will save money. You can also save money when you use a non-participating doctor or facility, but not as much.
With a PPO plan:
- You choose the doctors you want to use.
- Your health care is up to you and your doctor. You don’t need pre-service authorization for most covered treatment. (If you’re not sure whether a service is covered, you can avoid unplanned expenses by asking your doctor to contact the carrier in advance. When a claim is submitted, services are reviewed to determine coverage amounts.)
- You can choose different plans for different family members
What You Pay For Professional Services
By using a network provider, you could save up to 30-40 percent on out-of-pocket expenses each time you or your family receives medical care. If you do not use a network provider, you not only pay a higher amount of the negotiated fee, you are also responsible for charges over and above the negotiated fee. That's why it pays to stay within the network.
Negotiated provider fees help PPO members save. Here’s a generic example that compares how relative costs might break down using an in-network vs. out-of-network provider.
In-Network (participating provider)
Out-of-Network (non-participating provider)
Plan pays based on
Customary & Reasonable Fees
Provider’s usual fee
Carrier negotiated discount
Carrier negotiated fee
Insurance payment applied*
.7 x 600 = $420
.5 x 600 = $300
*Assumes any deductible has been met and you have not yet reached your out-of-pocket maximum. The deductible is the amount you pay each year for covered services before your plan begins paying part of the cost and the out-of-pocket maximum is the maximum amount for qualifying covered services you would have to spend in any one year before your plan pays 100% of your covered costs for most services.