Private Insurance Patients: Face-To-Face Requirements Explained

Private health insurance is becoming an increasingly popular option for those who want quick access to medical attention, with the demand for private GP appointments on the rise. Most private health insurance policies give patients access to private GP appointments, either face-to-face or digitally, with some policies automatically including this access and others offering it as an add-on. Face-to-face appointments are generally the most expensive type of private GP service, with virtual appointments being a cheaper alternative. However, virtual appointments may not always be suitable, particularly if a physical examination is required.

Private health insurance is a financial contract between a private organisation and a policyholder

Private health coverage is subject to significant requirements at the state and federal levels. In the US, the Affordable Care Act (ACA) of 2010 brought in many new requirements for federal regulation, but another federal law, the Employer Retirement Income Security Act (ERISA), has regulated employer-sponsored coverage for over 50 years. States have traditionally been the primary regulators of health insurance, and state protections continue to play a major role.

There are two main sources of private coverage: employer coverage ("group" coverage) and individually purchased insurance coverage ("nongroup" coverage). In 2023, about 165 million people under the age of 65 had coverage through an employer. Employer-sponsored coverage is usually offered to eligible employees and their dependents, such as spouses and children. Alternatively, individuals can purchase private health coverage for themselves and their family without employer involvement.

The regulatory framework for private health coverage has become increasingly complex, with a complicated system of overlapping state and federal standards. This federalism framework has created a sometimes precarious "marriage" between state and federal authority to implement health policy goals.

Private health insurance is subject to significant requirements at the state and federal levels

Private health insurance is subject to a multitude of requirements at both the state and federal levels. The regulatory framework for private health coverage has evolved into a complicated system of overlapping state and federal standards. While states have traditionally been the primary regulators of health insurance, the federal government has played an increasingly significant role over the past 50 years. The federal pension law, the Employer Retirement Income Security Act (ERISA), passed in 1974, applies to insured and self-insured private employer-sponsored health coverage. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) also created new federal requirements and a basic framework for how state and federal law now interact. Under this "federal fallback" structure, states may require that insurers in the group and individual markets, as well as state and local government self-insured plans, implement federal requirements on health coverage. If a state fails to "substantially enforce" these requirements, the federal government will enforce them.

The Affordable Care Act (ACA) of 2010 ushered in many new requirements for the federal regulation of private health coverage. The ACA established core market rules designed to expand coverage to most people in the U.S., including requirements for premium stabilisation and other efforts to protect the risk pool. Federal reforms have also sought to address the stability and affordability of health insurance, with key provisions including high-risk pools, reinsurance, and risk corridors. Federal requirements also include a growing list of minimum standards for how a plan is designed or operated, such as laws that prohibit plans from imposing annual dollar limits on coverage.

The regulatory framework for private health coverage is complex, with federal regulation differing based on the market/source of coverage, and special exceptions in regulations allowing certain types of private coverage to avoid meeting many insurance protections. The regulation of private health insurance is primarily handled by three federal agencies: the U.S. Department of Health and Human Services (HHS), the U.S. Department of Labor (DOL), and the U.S. Treasury Department. These agencies jointly issue regulations and other guidance on laws passed by Congress that place the same or similar standards across all private plans.

Private health insurance is regulated by the U.S. Department of Health and Human Services, the U.S. Department of Labor, and the U.S. Treasury Department

Private health insurance in the US is regulated by three federal agencies: the US Department of Health and Human Services (HHS), the US Department of Labor (DOL), and the US Treasury Department. These agencies have overlapping jurisdiction for most federal regulation of private health plans.

The regulatory framework for private health coverage has evolved into a complicated system of overlapping state and federal standards. The federal pension law, ERISA, passed in 1974, applies to insured and self-insured private employer-sponsored health coverage. The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) created new federal requirements and the basic framework for how state and federal law now interact.

The regulation of insurance has traditionally been a state responsibility. States license entities that offer private health insurance and have a range of insurance standards, including financial requirements unique to state law. However, the federal government has played an increasingly significant regulatory role over the past 50 years.

Private health insurance is offered by employers or can be purchased directly from an insurer

Private health insurance is a contract between an individual and a private health insurance company, which mandates that the insurer pays some or all of the individual's medical expenses as long as they pay their premium. It is a mechanism for people to finance their health care services and medications, protecting them from extreme financial costs.

Private health insurance can be obtained in two ways: through an employer or directly from an insurer.

Private Health Insurance Through an Employer

Also known as "group coverage", employer-sponsored coverage is offered to eligible employees and usually also to their dependents, such as spouses and children. In 2023, about 165 million people under the age of 65 had coverage through an employer. Private employers who sponsor group health plans could include a range of entities, from a single nationwide company with thousands of employees to a small local business with only a handful of employees.

Employers can either purchase coverage from an insurer for a set premium (a "fully-insured" arrangement) or use a "self-insured" arrangement where they assume the financial risk by directly paying all covered claims. Self-insured plans are largely not subject to state law but are governed primarily by federal law.

Private Health Insurance Purchased Directly from an Insurer

Also known as "nongroup coverage", this type of insurance is purchased by an individual directly from a private health insurance company without the involvement of their employer. Nongroup coverage can be purchased either on or off a Health Insurance Marketplace (or "exchange"). The ACA Marketplace offers ACA-compliant insurance with federal financial assistance for premiums and cost-sharing, while off-Marketplace insurance may include ACA-compliant plans as well as other types of coverage or financial products with lower premiums and less comprehensive coverage.

Private health insurance plans are usually of the following types: Health Maintenance Organisation, Exclusive Provider Organisation, Preferred Provider Organisation, and Point of Service

Private health insurance plans are usually of the following types:

Health Maintenance Organization (HMO)

HMOs are a type of health insurance plan that usually limits coverage to care from doctors who work for or are contracted by the HMO. They generally won't cover out-of-network care except in emergencies. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness. With an HMO, you will likely have the least freedom to choose your healthcare providers and the least amount of paperwork compared to other plans.

Exclusive Provider Organization (EPO)

EPOs are managed care plans where services are only covered if you use doctors, specialists, or hospitals within the plan's network, except in emergencies. EPOs offer a moderate amount of freedom to choose healthcare providers and do not require referrals from a primary care doctor to see a specialist. EPOs generally have lower premiums than Preferred Provider Organizations (PPOs) offered by the same insurer.

Preferred Provider Organization (PPO)

With a PPO, you have a moderate amount of freedom in choosing your healthcare providers and do not need referrals from a primary care doctor to see a specialist. PPOs offer more flexibility than HMOs and EPOs, allowing you to use out-of-network doctors, hospitals, and providers for an additional cost. However, you will have higher out-of-pocket costs for using out-of-network services, and there will be more paperwork involved in getting reimbursed.

Point of Service (POS)

POS plans blend the features of HMOs and PPOs. With a POS plan, you have more freedom to choose your healthcare providers than with an HMO. You will need a referral from your primary care doctor to see a specialist, and you will pay less if you use doctors, hospitals, and providers that belong to the plan's network. POS plans usually involve a moderate amount of paperwork if you use out-of-network providers.

Frequently asked questions