What is a PPO?

PPO (preferred Provider Organization) is a nationwide coverage. It includes preferred providers (contracted with the carrier) and non-preferred providers (not contracted with the carrier).

This type of plans offers more freedom of choice for the consumer and a wider network of providers (hospitals and physicians). The preferred providers will charge less (negotiated rate) then the non-preferred.This disadvantage of this type of plans is the higher out of pocket cost for services rendered.

What is an HMO?

HMO (Health Maintenance Organization) is a type of plans that covers in sate only. This is a smaller network then the PPO and the member has to choose a PCP (primary care physician) that acts like a gatekeeper. You have to go to your PCP to get a referral to a specialist (this excludes OBGYN). The advantage of these plans is the low copay related to each service rendered.

What is an H S A?

H S A (Health Savings Accounts) are a special type of plans with a low monthly premium. These plans include a high deductible that should be met before services are covered. The member can use pre-tax dollars to pay for these services.

What is an EPO?

EPO (Exclusive Provider Organization) is a PPO plan that covers in state and in network only. These plans have a more restricted network and offer no coverage for out of network providers. You still have the flexibility of a PPO in network and in state only.

What is Open Enrollment?

Open enrollment begins October 1st 2013 and ends March 1st 2014. If your enrollment and first payment are received by the 15th of the month, your coverage will begin on the first day of the next month (For example if you applied and paid by February 15, your coverage will start March 1st). If your enrollment and first payment are received on or after the sixteenth of the month, your coverage will begin on the first day of the second month (For example if you applied and paid by February 16, your coverage will begin April 1st).

What is a deductible?

A deductible is the amount the member should pay first before the insurance plan kicks in. On a traditional plan, the deductible applies to all services with no co-payment.

What is a Co-pay?

A co-pay is a fixed dollar amount for specific services rendered such as an office visit or Chiropractic visit. Copays are more usual on an HMO plan.

What is Co-insurance?

Co-insurance is a term that defines a cost sharing between the insurance company and the insured. It usually starts after the deductibles have been met and ends at the maximum out of pocket.

For example a Silver plan has a coinsurance of 70%/30% which means the carrier will pay 70% of the charges after deductibles and the member 30%, not to exceed the max out of pocket.

What is the Max out of Pocket?

The MOP (max out of pocket) is the most a member will pay for services rendered in a calendar year. Once the MOP is met, the insurance company will pick up the cost for all services rendered in network until the end of the calendar year (January 1st until December 31st).The MOP for any market place plan in 2014 is 6,350 for individual plans and 12,700 for a family plan. The MOP includes all copays (office visits and Prescriptions drugs), deductibles and co-insurance.

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