Group Benefits

Health/ Major Medical

Health Maintenance Organization (HMO)

A type of health care plan that offers patients a low deductible and little or no co-payments for visits to approved physicians and hospitals. “Pure” HMOs require members to use doctors and hospitals that belong to that HMO network.

Advantages

  • The employee’s out-of-pocket medical expensesare generally limited to office visit co-payments and a minimal dollar amount, if any, for hospitalization.
  • HMOs generally offer certain “well-care” services as a covered benefit that may not normally be a part of other types of health plans, such as immunizations, annual physicals, and well-child visits.
  • Decisions regarding health care are generally made by the HMO, and the patient has access to a wide variety of skilled professionals.

Disadvantages

  • The patient has NO coverage if they seek medical care from providers outside of the HMO providers.
  • The patient has no freedom of choice as to which providers he seeks care from.
  • The patient has no freedom of choice if there are several treatment options available from which to choose.
  • The patient has no freedom of choice as to where the services are rendered.
  • Certain drugs – usually name-brand drugs – may not be covered under this plan.
  • There may be treatment protocols which must be tried first, before treatment plans can become more “creative”.

Preferred Provider Organization (PPO)

A PPO encompasses features of an HMO and private insurance. Plans are usually made up of a pre-selected group of physicians and hospitals that have contracted with insurance companies or employers to provide medical care at a discounted rate. Patients are encouraged to use “in network” providers or risk paying a greater percentage of the bills. Often, there is a “co-payment”, or small fee required each time you visit your doctor. You may choose doctors and hospitals that are not in the PPO network for a slightly higher out-of-pocket fee.

Advantages

Employees can use the Plan’s “Preferred Providers” at a minimal out-of-pocket expense (usually a nominal office visit co-payment), and do not have to meet a calendar year deductible or pay a co-insurance for the services they receive.

If the Plan’s“Preferred Hospitals” are used, the out-of-pocket expense to the patient is generally substantially lower than it would otherwise be.

Many veryprestigious hospitals and physicians are members of PPOs.

Patients also have the option of having some coverage if they choose touse non-preferred providers, although their out-of-pocket expense is much greater, and they may have to meet a calendar year deductible and pay a co-insurance for non-preferred provider services. This option, however, if very appealing to people who want to continue to see one non-preferred provider (for an annual gynecological exam, for example), but are willing to change their other doctors for “preferred” providers.

Disadvantages

Some freedom of choice is lost by the patient if they choose to use only “preferred providers.”

Types of PPOs

  • There are two types of PPOs. One is a “non-gatekeeper” PPO, and the other is a “gatekeeper” PPO.
  • A“non-gatekeeper” PPO gives employees a provider directory that includes the names of specialists, since patients may go directly to them for medical care, without a referral form from a primary care physician.
  • A “gatekeeper” PPO requires that the patient seek medical care first from a primary care physician. If the patient seeks medical care directly from a specialist, without a referral from a primary care physician, he or she may have to pay the specialist’s charges in full, with no assistance from the insurance company.

Point-of -Service Plan (POS)

A point of service plan is a combination of two types of insurance coverage, first, an indemnity or fee-for-service plan, and second, an exclusive provider organization plan or a health maintenance organization plan. The patient can still realize substantial savings in out-of-pocket expenses if they use the HMO plan, but also has the option of continuing to use non-HMO providers, at much greater out-of-pocket expense.

Dental

Dental HMO/Prepaid Dental Plans

These plans provide affordable care through a network of highly qualified dentists. There are no waiting periods, calendar year maximums, or deductibles and no claim forms. With these plans, each enrolled family member may choose their own dentist from the directory and the plans are comprehensive, covering more procedures than many other dental benefits providers.

Dental Indemnity/PPO Plans

We offer a variety of indemnity type plans, all with access to a network of contracted dentists. They follow the traditional dental insurance plan design with calendar year maximums, deductibles and coinsurance percentages. We have variations of the standard 80 and 90 percentile plans and we also offer MAC (Maximum Allowable Charge) plans as an alternative. Voluntary and employer paid options are available.

Other Group Benefits

Vision & Prescription

We offer a variety of independent vision plans including full indemnity (insurance plans) and schedule (supplementary) plans.

Group Life and Accidental Death and Dismemberment Insurance (AD&D)

High quality, competitively priced Life Insurance products including permanent, term, combination and variable policies.

Long & Short-Term Disability

Market-leading Disability Insurance products covering total or partial disability of professionals, business executives, small business owners and others.

Long-Term Care

Comprehensive Long-Term Care Insurance reimburses some or all of the costs of care received in settings such as the home, the community, alternate living facilities or nursing facilities

Critical Care Coverage

Specified Disease Insurance Plans complement major medical coverage by helping employees pay the direct and indirect costs associated with critical illness.

New York State Disability Insurance (DBL)

Any employer of One or More Employees in the state of New York must provide coverage. This includes employers of one or more domestic employees working in a private home at least 40 hours per week. Benefits are: 50% of wages to a maximum of $170/wk for up to 26 weeks, after 7 days of disability.

 

 

 

 

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