Prominence Point of Service
New health insurance plans recently released from Prominence Health Plans now have much lower monthly costs. These plans can do this through something called a Point of Service model. Most people are familiar with HMO and PPO plans and how they work, but these new Prominence Point of Service plans from Prominence offer the low monthly prices of an HMO with the flexibility of being able to see PPO doctors.
Let’s start with the basics – Understanding the doctors’ lists.
Almost every insurance plan available today has a list of approved doctors. By using doctors contracted with the insurance company, or on “the list”, the patient ends up saving the most amount of money for the visit. When a patient goes to a doctor not on the list, or “outside the network” the patient ends up spending much more for the visit.
Too many acronyms…. simplify.
Today the type of health insurance plan you buy has the most to do with which doctors are covered. Insurance companies love acronyms, but there are only a few you need to know.
HMO plans only cover doctors on their list (excluding emergencies and exceptional situations). In exchange, these plans have a very inexpensive monthly cost.
PPO plans usually have a larger list of covered doctors and they cover doctors who aren’t contracted with the insurance company, but just because the doctor is “covered” doesn’t mean the insurance company is going to pay for the visit. Just like HMO plans, PPO plans give patients the lowest prices when they use doctors who are on the list.
The Prominence Point of Service plan is a combination of both of these. You have 3 categories of doctors you can see. 1. doctors who are on the HMO list, 2. doctors who are on the PPO list, or 3. doctors who are not on either list. By using doctors on the HMO list, patients pay the least for the visit. If they can’t or don’t want to see a doctor on the HMO list, the patient can see doctors on the PPO list for a slightly higher price. If the doctor is not covered under either list but the patient still needs to see that doc, the Point of Service plan will still cover it, but the patient will pay the most.
For example, let’s say I want to go see a Primary Care doctor and I’m on a Prominence Point of Service plans with benefits similar to the following:
Primary care doc. | Specialist. | Deductible. | Coinsurance. | Maximum Out of Pocket | |
HMO | $20 | $40 | $0 | 10% | $3,000 |
PPO | $35 | $70 | $1,000 | 20% | $5,000 |
OUT OF NETWORK. | N/A | N/A | $2,000 | 40% | $7,500 |
Every doctor will fall into one of these three categories – in HMO, in PPO or Out of Network. If I have the option I want to pay the least, so when choosing a primary care doctor I’m going to try to find one that’s on the HMO list. This way I only have to pay $20 for the visit.
If the doctor I need to see isn’t on the HMO list, or for some reason isn’t available I will pay $35 and see a doctor on the PPO list.
However, if I discover my doctor is not covered at all, or “out of network”, it’s better to either change doctors, change insurance companies (if it’s available) or be ready to pay cash for the visit. The “N/A” means the insurance company will apply a portion of the visit to the $2,000 deductible, but if I haven’t paid $2,000 in medical expenses yet this year I pay for the entire visit.
Traveling?…. Take it with you!
Prominence Point of Service plans also work outside of Nevada. They use a nationwide list of PPO doctors called First Health Network. If you’re outside of Nevada you can jump online, find a doctor and end up saving a lot of money by using these doctors.
Let’s talk premium… How much per month is this going to cost?
The interesting thing about the Prominence Point of Service plans is they’re actually cheaper than the PPO plans, even though you have the option to use PPO doctors! The reason for this has to do with the agreement between the doctor and the insurance company. It would take an entire book to explain the details, but the result is these plans are cheaper than the PPO plans. However, they are NOT usually cheaper than the HMO plans. HMO plans don’t pay a dime to anyone other than their contracted HMO doctors. In exchange for being so limited, members of an HMO save a lot per month.
Overall the Prominence Point of Service plans are both low cost and you have the ability to use multiple doctors.
