760.245.7733 (voice) 760.245.4224 (fax) 760.245.7733 (text) info@nwiins.com (email)
760.245.7733 (voice)760.245.4224 (fax)760.245.7733 (text)info@nwiins.com (email)

Health Insurance 101

The Affordable Care Act ushered in major changes to health insurance. The most noticeable change is that preexisting conditions. Now it doesn't matter what your health history is, what your family health history is, or even what your current health condition, you are no longer uninsurable.

Whether your insurance comes from your employer or you purchase insurance on your own, most Americans have a managed-care plan. There are different types of managed-care plans, the most common types of managed-care plans are health maintenance organizations (HMO) and preferred provider organizations (PPO).


Members of an HMO must select a primary-care physician. When seeking treatment, members must obtain a referral from their primary-care physician to get services from another physician in the network. Because the cost is spread out among a limited number of members, HMOs can be less expensive than PPOs. However, costs of services performed by a doctor outside of an HMO network may be much higher, resulting in a higher out-of-pocket expense for the patient.


Members of a PPO have greater flexibility when choosing services provided by physicians outside the plan's network. PPOs may include additional benefits such as prescription drug plans. The premium for a PPO tends to be greater than an HMO.

There are advantages and disadvantages to each of these health insurance plans. Choosing between the two should be made only after a careful review of each plan's benefits, the accessibility and size of the network, limits, and the out-of-pocket expenses.

Individual vs. Group Plans

Many Americans join a group health insurance plan offered through their employer or another organization. Group plans tend to be less expensive and offer broader coverage than individual plans.

Those without access to group health insurance or who choose to forego group coverage can purchase an individual health plan for their family and themselves.

The Basics

Health insurance plans normally include a deductible or co-payment for services. This is the amount you will pay out-of-pocket for services before the insurance coverage pays. Deductibles may differ depending on the service performed. For some services, the policy may include coinsurance--this is the percentage of the cost you will pay out of pocket versus the percentage paid by the insurance company. Before choosing a plan, carefully review the limits for different types of services and make sure you understand any out-of-pocket expenses. Choosing higher deductibles, co-payments and coinsurance percentages means more out-of-pocket cost to you; however, this will also reduce your overall premium.

Dental Insurance 101

Dental insurance works in much the same way that medical insurance works. For a specific monthly rate (or "premium"), you are entitled to certain dental benefits, usually including regular checkups, cleanings, x-rays, and certain services required to promote general dental health. Like health insurance plans, dental insurance plans are usually categorized as either Indemnity or managed-care plans (Dental PPO plans fit in this latter category). Put broadly, the major differences concern choice of dental care providers, out-of-pocket costs and how bills are paid. Typically, Indemnity plans offer a broader selection of dental care providers than managed-care plans. Indemnity plans pay their share of the costs for covered services only after they receive a bill (which means that you may have to pay up front and then obtain reimbursement from your insurance company). Managed-care plans typically maintain dental provider networks. Dentists participating in a network agree to perform services for patients at pre-negotiated rates and usually will submit the claim to the dental insurance company for you.

Dental PPO (Preferred Provider Organization or Participating Provider Organization) plans are perhaps the most common type of managed care dental insurance plans. Most Dental PPO plans require you to pay a deductible. With a Dental PPO plan the patient typically obtains care through a network of dental providers who agree to serve the plan's members at reduced rates. When you use a network provider, you will typically pay a certain percentage (e.g. 20%) of the reduced rate, and the insurance company will pay the remaining percentage (e.g. 80%). As a member of a Dental PPO plan, you may use dentists outside of the Dental PPO plan network, but you will typically only be reimbursed based on the amount that a network dentist would have accepted as payment in full. The rest of the total charges will be considered the patient's responsibility.

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