In the previous issue, I summarized a little about “cancer insurance” in Japan, and this time I would like to research and summarize “cancer insurance” in the U.S., which is also of interest to many of you.
If you have not yet read the previous article on “Cancer Insurance” in Japan, please refer to that article as well.
Private Medical Insurance in the U.S.
Private Medical Insurance
Most U.S. citizens have private medical insurance either through their employer or purchased privately. The following are some of the types of private health insurance
HMO (Health Maintenance Organization)
This is one of the most widely used medical insurance plans in the United States. Although the insurance requires the use of specific medical facilities and providers, the premiums are relatively inexpensive, and it is characterized by its focus on preventive care.
How HMOs Work
HMOs have a network of medical facilities and health care providers available to subscribers. By using medical facilities and providers within this network, the co-payments for premiums are lower. On the other hand, using out-of-network medical facilities and providers will result in higher copayments.
To use an HMO, you must first select a primary care physician (PCP), who will provide initial consultations, tests, and referrals to specialists as needed.
Advantages of HMOs
Relatively inexpensive premiums: premiums are less expensive than other private medical insurance such as PPO and EPO.
Focus on preventive care: Regular checkups and vaccinations are recommended to help detect and treat illnesses in their early stages.
Easier to manage medical expenses: Since you receive medical care through your PCP, you can avoid wasting money on medical expenses.
Disadvantages of HMOs
Limited choice of medical facilities and providers: Only in-network medical facilities and providers are available, so your choices are limited.
May require referrals: You may need a referral from your PCP to see a specialist.
May have limited emergency coverage: Out-of-pocket costs may be higher for emergency visits to out-of-network providers.
Who is suited for an HMO?
People who want to reduce their medical expenses: HMOs are suitable for people who want to reduce their medical expenses due to relatively low premiums and easy management of medical expenses.
People who value preventive care: HMOs are suitable for people who value preventive care, as they encourage regular checkups and vaccinations.
People who want to use a specific health care provider: HMOs are an option for people whose regular health care providers are in the HMO network.
PPO (Preferred Provider Organization)
Unlike HMOs, PPOs can be used not only by in-network providers but also by out-of-network providers. Although co-payments are higher, it is characterized by a wider choice of medical facilities and providers and greater flexibility.
How PPO works
PPOs have a network of medical institutions and providers available to subscribers. When medical institutions/providers within this network are used, the co-payment of insurance premiums is lower. On the other hand, if you use a medical institution/provider outside the network, your copayments will be higher.
PPOs do not require you to select a primary care physician (PCP).
This is the difference between ↑HMOs.
Advantages of PPO
Wide choice of medical institutions and providers: You can use not only in-network medical institutions and providers, but also out-of-network medical institutions and providers.
Greater flexibility: You can freely choose your health care provider without the need to select a PCP.
Easy access to specialists: You can see a specialist without a referral.
Flexible emergency care: If you visit an out-of-network provider in an emergency, your co-pay will be lower than with an HMO.
Disadvantages of PPO
Higher premiums: premiums are higher than HMOs.
Higher out-of-pocket costs: If you use out-of-network providers, your out-of-pocket costs will be higher.
Difficulty in managing medical expenses: Even if you use in-network providers, you will still have co-payments, making it more difficult to manage your medical expenses.
Who is a good candidate for PPO?
People who value choice of medical institution/provider: This is for people who want to choose the medical institution/provider that best suits their needs and who want to see a specific specialist.
People who want freedom: People who want the freedom to choose their own medical institution/provider without the need to select a PCP.
People who value emergency care: Suitable for people who may need to visit an out-of-network medical facility in an emergency
Summary
In this article, we have introduced two types of insurance in the United States.
I was going to summarize them in one article, but since there were more than I imagined and I could not summarize them all, I will summarize them in another article.
