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QUESTIONS:
ANSWERS:
What is a PPO?
A PPO is a Preferred Provider Organization. As a member of a PPO, you can use the doctors and hospitals within the PPO network or
go outside of the network for care. You do not need a referral to see a specialist.
- If you obtain care from a medical provider outside of the PPO network, you will pay more for the service.
For example, a PPO might pay 90 percent of the cost for a visit with an in-network doctor but only 70 percent of the cost for a
visit to a non-network doctor.
- You will typically pay a copayment for each visit/service. These copayments are typically higher than an HMO copayment but not always.
- You will usually be responsible for paying an annual deductible.
If you join a PPO, you should find you have more flexibility than with an HMO, but your total out of pocket costs are likely to be somewhat higher.
What is an HMO?
An HMO is a Health Maintenance Organization. As a member of an HMO, you select a primary care physician from a list of doctors in that HMO's network. Your primary care physician will be the first medical provider you call or see for a medical condition. He or she will make any needed referrals to a medical specialist. Typically, these specialists will be part of the HMO network.
- If you obtain care without your primary care physician's referral or obtain care from a non-network member, you may be responsible
for paying the entire bill. (with exceptions for emergency care)
- With some HMOs, you pay nothing when you visit in-network doctors. With other HMOs there may be a small copayment for the visit or
service.
- With most HMOs you will not be responsible for paying a deductible.
If you join an HMO, you should find that you have few out-of-pocket expenses for medical care -- as long as you use doctors or hospitals
that are part of the HMO.
What is a MSA?
An MSA is a Medical Savings Account. It is a tax-advantaged personal savings account used in conjunction with a high deductible health
policy. Individuals can contribute money to this account on a pre-tax basis to set aside money for qualified medical care and expenses,
including annual deductibles and copayments.
What is a POS?
POS is a Point-of-Service Plan A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred
provider organizations (PPOs). You can decide whether to go to a network provider and pay a flat dollar or to an out-of-network provider
and pay a deductible and/or a coinsurance charge.
What is an EPO?
An EPO is health plan that provides health care services to plan members that allows members to receive
in-network care from a network of participating hospital, physicians, and other health-related facilities and
providers of care.
What is an Indemnity Plan?
An indemnity plan is commonly known as a fee for service or traditional plan. If you select an Indemnity plan you have the freedom to
visit any medical provider. You do not need referrals or authorizations; however, some plans may require you to precertify for certain
procedures.Most indemnity plans require you to pay a deductible. After you have paid your deductible, indemnity policies typically pay a
percentage of "usual and customary" charges for covered services; often the insurance company pays 80% and you pay 20%. Most plans have
an annual out of pocket maximum and once you've reached this they will pay 100% of all "usual and customary" charges for covered services.
Many health insurance companies have moved away from indemnity plans and are instead offering managed care plans such as HMOs and PPOs.
You may have few or no indemnity plan choices in your area.
What is a provider?
A provider is a hospital, healthcare facility, physician or other medical professional that provides healthcare services.
What is a Primary Care Physician (PCP)?
A physician or other medical professional who serves as a group member's first contact with a plan's healthcare system. Also known as a
primary care provider, personal care physician, or personal care provider.
What is a co-payment?
A copayment is a fixed dollar amount or a percentage that you pay for each visit/service. For example, with some plans you may pay a fixed
amount such as $5 or $10 per visit. Other plans will charge you a percentage of the total fee for the visit. So if your copayment is 10% and the
doctor visit was $200, you would pay 10% which, in this case, would be $20.
What is a deductible?
A deductible is the amount of annual medical expenses that a health plan member must pay before the plan will begin to cover expenses. For
example, if your plan has a $500 deductible, you will pay the first $500 of your medical expenses before your health plan begins paying the
expenses. Only expenses for covered services apply towards the deductible. For example, if you paid $100 for a visit to a chiropractor but the
plan does not consider chiropractic care a covered expense, then the $100 will not apply toward your annual deductible.
What is the difference between an in-network and an out-of-network medical provider?
An in-network medical provider is within the approved network of providers for a particular health plan. Out-of-network providers are not on the
list. If you visit a doctor within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network
doctor. In many cases, the insurance company will not pay anything for services you receive from outside their network; however, there are
exceptions to this.
As a general rule, HMOs tend to have smaller provider networks than PPOs. In HMO and PPO plans, referrals to specialists will be to doctors within
the network. Indemnity plans typically do not have networks; you go to whatever doctor you want.
Can I buy health insurance in California for less if I buy directly from the insurance company?
No. Health Care in California is regulated by the Department of Insurance and the Department of Managed Care. Every carrier must publish their
premiums. These rates cannot be reduced or raised without submitting a written quote. In Fact, the industry prefers consumers use a licensed
Brokerage like Business Insurance Services as there is no cost for using an agency services. |
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