FAQs: Medical

What is a preferred provider organization (PPO) plan, and how does it work?
A preferred provider organization (PPO) plan works for you in two ways: through a panel or network of physicians and other service providers (such as hospitals and labs), or through providers you select that are not in the network. Each time you or a covered family member needscare, you choose whether to see an in-network or an out-of-network provider. Network providers are listed in your plan’s provider directory. When you use an in-network provider, also called “going in-network,” you generally receive a higher level of benefits. Also, fees from in-network providers tend to be lower, because the providers and the network have negotiated to have the providers accept certain fees for certain services.

With a PPO plan, do I name a primary care physician (PCP)?
The PPO plan does not require you to name a primary care physician (PCP) or coordinate your care through a particular doctor.

What are the advantages of obtaining my care from in-network providers?
There are several advantages when you go in-network. Generally your deductible may be lower than it would be for out-of-network expenses. You don’t need to submit claim forms and wait to be reimbursed by your plan. Your in-network provider obtains any needed preauthorization for you. You generally receive a higher level of benefits because participating providers (doctors, hospitals and other health care facilities) have agreed to provide their services at lower fees. Some plans provide preventive care services in-network that are not covered out-of-network. Some plans limit covered services out-of-network, but offer these services without a limit on the number of visits when the care is provided in-network.

How does the PPO plan work when I go out-of-network?
Generally, you may use any covered health care provider you choose. However, your cost will generally be higher and you have certain added responsibilities. For example, each year, you must pay part of your eligible out-of-network expenses before the PPO plan begins to pay benefits. This amount is called the deductible.

When do I need to file a claim form?
You may not need to file a claim form when you see in-network providers. When you do need to file a claim form, as you need to when you go out-of-network, your doctor may handle your expense in one of two ways. Most doctors require you to pay the bill right away. In this case, get a receipt and file it with a claim form to be reimbursed. If the expense is covered, you will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you have more than one health insurance plan and have received an Explanation of Benefits (EOB) form from another health care plan, be sure to include a copy with your claim. Sometimes doctors are willing to wait for payment. In this case, you or your doctor will file the receipt and completed claim form with your health care company. The health care company will pay the doctor for the part of your expense the plan will cover. The doctor will then bill you for the part the plan did not pay.

What happens if I need specialty care that is not available from in-network providers where I live?
You may be referred to an out-of-network provider if you need specialized care that your health care company determines to be medically necessary and that is not available through an in-network provider in your area. As long as you use the provider you’re referred to by your health care company and follow your plan’s rules, you’ll be covered for that care at in-network benefit levels.

What happens in an emergency?
In a true emergency, get the care you need as quickly as you can. If you are able, contact member services for your health care company at the number on your ID card, even in an emergency. However, even if you are unable to contact member services, get the care you need. Even if you need to go out-of-network, your plan will cover emergency care at in-network benefit levels as long as you follow the plan rules Check to see how your plan defines a true emergency.

Examples typically include severe bleeding, chest pain, and unconsciousness. Also check to see how soon after the onset of the emergency you must notify your health care company in order to be covered in-network.

What happens if I need care while I’m traveling?
If it’s not an emergency and you need care while traveling, call member services for your health care company at the number on your ID card. Member services can refer you to an in-network provider In a true emergency, get the care you need as quickly as you can. If you are able, contact member services even in an emergency, and your health care company can help you decide where to go for care. However, even if you are unable to contact member services, get the care you need. Even if you need to go out-of-network, your plan will cover emergency care at in-network benefit levels as long as you follow the plan rules. Check to see how your plan defines a true emergency.

Examples typically include severe bleeding, chest pain, and unconsciousness. Also check to see how soon after the onset of the emergency you must notify your health care company in order to be covered in-network.

What is a deductible?
A deductible is the part of eligible expenses you must pay before the plan begins to pay a percentage of your eligible expenses.

Are there expenses that don’t count toward my deductible?
Yes. Some of your expenses will not count toward your deductible. For example, any penalty you may pay because you failed to preauthorize treatment through your health care company will not count.

For out-of-network care, amounts your care provider charges above the plan’s allowable amount for a given service also will not count toward your deductible.

What is coinsurance?
After you satisfy the deductible, the plan will reimburse you for a percentage of your eligible expenses. The percentage you pay is called your coinsurance percentage.

What is a copayment?
A copayment generally applies to in-network care. When you stay in-network, you pay only a fixed amount at the time you receive services. That amount is called your copayment.

What is preauthorization?
Preauthorization is the process by which a healthcare company or preauthorization company reviews the proposed treatment and tells you and your doctor how benefits may be paid. If you receive care out-of-network, you must obtain preauthorization for certain covered expenses such as a hospital stay. Some plans also require preauthorization for certain in-network services. If you don’t get the required preauthorization, your cost will be higher because the benefits payable by the plan will be reduced or the expenses will not be covered at all.

What’s the amount known as the “allowable amount,” the “U&C amount” or the “R&C amount”?
The terms “allowable amount,” “U&C amount” or “R&C amount” vary by plan but refer to the same thing. The allowable, usual and customary or reasonable and customary amount is the amount usually charged for a given service by most providers in your area. This amount is determined by your health care plan. If your doctor charges you more than this amount, you will not only be responsible for your deductible and coinsurance, but also for the entire difference between the U&C amount and the amount your provider charged. This concept only applies to out-of-network care, because in-network providers have agreed to negotiated fees that are by definition allowable amounts For example, suppose you receive a service for which the “U&C amount” is $100 but your doctor charges you $110. The health care company will multiply the percentage the plan pays for that service by $100. So even if the service were covered at 100%, you would pay the $10 difference ($110 charge minus $100 U&C).

What are covered services?
Covered services are services covered by the plan. No medical plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services.

What is an out-of-pocket maximum?
An out-of-pocket maximum is the most you would have to pay “out of your own pocket” for eligible expenses. Not all plans have an out-of-pocket maximum. Check your Benefits Summary for details.

With a plan that has an out-of-pocket maximum, once you reach the out-of-pocket maximum for a given year, the plan would pay all eligible expenses for covered services. Not all expenses count toward an out-of-pocket maximum. Expenses for services that are not covered under the plan, amounts over any allowable amount limit, and penalties for not preauthorizing care when needed would not count toward your out-of-pocket maximum.

What is a lifetime maximum?
A lifetime maximum is the most that will be paid by the plan for covered services for a given plan member. Not all plans apply a lifetime maximum, and some plans have different lifetime maximums for different services or for in-network and out-of-network services. Once you reach the lifetime maximum, you pay all expenses over that amount.

What is a point-of-service (POS) plan and how does it work?
A point-of-service (POS) plan works for you in two ways: in-network and out-of-network. When you enroll in a POS plan, you select a participating PCP for each enrolled family member. You may select any PCP from your plan’s network provider directory. When your PCP coordinates your medical care, either by providing that care or by giving you a referral to see another provider, this is considered “in-network.” When you go directly to a provider other than your PCP, this is “out-of-network. You choose whether to go in-network or out-of-network each time you need care. However, if you choose to go out-of-network, you will pay a larger share of the cost.

What is a primary care physician (PCP)?
With some POS plans, you are asked to select a primary care physician (PCP) to be the personal doctor for each enrolled family member. If you are asked to select a PCP, you may select any participating PCP from your plan’s network provider directory.

What are the advantages of going in-network?
There are several advantages when you go in-network. Generally, you don’t need to submit claim forms and wait to be reimbursed by your plan. Your network provider obtains any needed precertification for you. In most cases, you only pay a copayment (fixed dollar amount) at the time you receive covered services. After you pay your copayment, you owe no more payments for the covered services. Some plans provide preventive care services in-network that are not covered out-of-network. Some plans have fewer limits on covered services you receive in-network.

How does the POS plan work when I go out-of-network?
When you go out-of-network, you may use any covered health care provider you choose. However, your cost will generally be higher and you have certain added responsibilities.

My plan requires me to select a PCP when I enroll. How do I do so?
When you enroll, you may select any PCP from your plan’s network provider directory for each covered family member. Your enrollment materials will request your PCP’s name, or a code for that PCP from the provider directory. You will generally find PCPs in the areas of family practice, general practice, internal medicine, or pediatrics. Some plans allow a woman to name one PCP for her primary care and a second specialist in Obstetrics and Gynecology for services such as pelvic exams and Pap smears. It’s a good idea to check with your health care company before you select a PCP. Some PCPs have “full” practices and cannot accept new patients, and others may no longer be participating in the network.

Can I change my PCP?
Yes. You or a covered family member may change PCPs for any reason. Just call the member services number on your ID card.

When do I need to file a claim form?
You may not need to file a claim form when you go in-network. When you do need to file a claim form, as you need to do in most cases when you go out-of-network, your doctor may handle your expense in one of two ways. Most doctors require you to pay the bill right away. In this case, get a receipt and file it with a claim form to be reimbursed. If the expense is covered, you will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you have more than one health insurance plan and have received an Explanation of Benefits (EOB) form from another health care plan, be sure to include a copy with your claim. Sometimes doctors are willing to wait for payment. In this case, you or your doctor will file the receipt and completed claim form with your health care company. The health care company will pay the doctor for the part of your expense the plan will cover. The doctor will then bill you for the part the plan did not pay.

What happens if I need specialty care that is not available from in-network providers where I live?
If you need specialized care, if your health care company determines that it is medically necessary, and if the care is not available through an in-network provider in your area, you may be referred to an out-of-network provider. As long as you use the provider you’re referred to by your health care company and follow your plan’s rules, you’ll be covered for that care at in-network benefit levels.

What happens if I need care while I’m traveling?
If it’s not an emergency and you need care while traveling, call your health care company at the member services number on your ID card for referral to an in-network provider In a true emergency, get the care you need as quickly as you can. If you are able, contact your health care company even in an emergency. Your health care company can help you decide where to go for care. However, even if you are unable to contact your health care company, get the care you need. Even if you need to go out-of-network, your plan will cover emergency care at in-network benefit levels as long as you follow the plan rules. Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain and unconsciousness. Also check to see how soon after the onset of the emergency you must notify your health care company in order to be covered in-network.

What is a Health Maintenance Organization (HMO) and how does it work?

What is a primary care physician (PCP)?
With some HMOs, you are asked to select a primary care physician (PCP) to be the personal doctor for each enrolled family member. If you are asked to select a PCP, you may select any participating PCP from your HMO’s provider directory.

What are the advantages of an HMO plan?
There are several advantages when you belong to an HMO. Generally, you don’t need to submit claim forms and wait to be reimbursed by your plan. Your HMO provider obtains any needed precertification for you. In most cases, you only pay a copayment (fixed dollar amount) at the time you receive covered services. After you pay your copayment, you owe no more payments for the covered services. HMO plans typically cover certain preventive care services.

How does an HMO work when I obtain care outside the HMO?
Generally, HMO plans do not cover services provided outside the HMO except in certain emergency situations.

My plan requires me to select a PCP when I enroll. How do I do so?
When you enroll, you may select any PCP (primary care physician) from your HMO’s network provider directory for each covered family member. Your enrollment materials will request your PCP’s name, or a code for that PCP from the network provider directory. You will generally find PCPs in the areas of family practice, general practice, internal medicine, or pediatrics. Some plans allow a woman to name one PCP for her primary care and a second specialist in Obstetrics and Gynecology for services such as pelvic exams and Pap smears It’s a good idea to check with your HMO before you select a PCP. Some PCPs have “full” practices and cannot accept new patients, and others may no longer be participating in the network.

Can I change my PCP?
Yes. You or a covered family member may change PCPs for any reason. Just call the member services number on your ID card.

Do I ever need to file a claim form with an HMO?
You generally don’t need to file a claim form when you see your PCP. Just show your ID card when you receive services so the office knows to charge you a copayment and bill your HMO plan for the balance. The plan works the same way when your PCP refers you to another HMO doctor or hospital for care. Just show your ID card and pay your copayment In a true emergency, your eligible expenses may be covered even if you had to go outside the HMO as long as you follow the HMO plan’s rules. In this case, the provider will bill you directly. You then need to submit a claim form to be reimbursed. You will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you received an Explanation of Benefits (EOB) statement from another health care company, be sure to include a copy with your claim form.

What happens if I need specialty care that is not available from my HMO?
You may be referred to a non-HMO provider if you need specialized care that your HMO determines to be medically necessary and the care is not available through the HMO in your area. As long as you use the provider you’re referred to by your HMO and follow your HMO’s rules, you’ll be covered for that care.

What happens in an emergency?
In a true emergency, get the care you need as quickly as you can. Assuming you are able, try to contact your HMO, even in an emergency. However, even if you are unable to contact your HMO, get the care you need. Even if you need to seek care from a non-HMO provider, your plan will cover emergency care as long as you follow the plan rules Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain and unconsciousness. Also check to see how soon after the onset of the emergency you must notify your HMO in order to be covered.

What happens if I need care while I’m traveling?
If it’s not an emergency and you need care while traveling, call your HMO and your HMO can help you arrange a referral In a true emergency, get the care you need as quickly as you can. If you are able, contact your HMO, even in an emergency. However, even if you are unable to contact your HMO, get the care you need. Even if you need to seek care from a non-HMO provider, your plan will cover emergency care as long as you follow the plan rules. Check to see how your plan defines a true emergency. Examples typically include severe bleeding, chest pain and unconsciousness. Also check to see how soon after the onset of the emergency you must notify your HMO in order to be covered.

Do I pay a deductible?
A deductible is the part of your eligible expenses you pay each year before the plan begins to pay benefits. Check your Benefits Summary for details.

Do I pay coinsurance?
Coinsurance is the percentage of eligible expenses you pay after you meet any deductible required by your plan. Check your Benefits Summary for details.

What is a copayment?
A copayment is a fixed amount you pay at the time you receive services.

What is preauthorization?
Preauthorization is the process by which an HMO reviews the proposed treatment and tells you and your doctor how benefits may be paid. Generally, preauthorized care is paid at the highest level of coverage. You must obtain preauthorization for certain covered expenses such as a hospital stay. If you don’t get the required preauthorization, your cost will be higher because the benefits payable by the plan will be reduced or the expenses will not be covered at all.

What are covered services?
Covered services are services covered by the plan. No medical plan covers everything. If you obtain services that are not covered services, you pay the full cost for those services

What is an open access Health Maintenance Organization (HMO) and how does it work?
An open access Health Maintenance Organization (HMO) provides health care services to enrolled members through a panel of HMO providers. When you enroll in an open access HMO, your plan may or may not ask you to select a participating PCP for each enrolled family member. If you are asked to select a PCP, you may select any participating PCP from your HMO’s provider directory.

With an open access HMO, you may see any provider in the HMO’s panel without getting a referral. With an HMO plan, you generally pay a fixed amount each time you receive care. Coinsurance typically does not apply with an HMO Except in an emergency as defined by the plan, or with previous approval through the plan’s authorization procedures, only services provided by or referred by an HMO panel provider will be covered under an HMO.

Do I ever need to file a claim form with an open access HMO?
You generally don’t need to file a claim form with an open access HMO. Just show your ID card when you receive services so the office knows to charge you a copayment and bill your HMO plan for the balance In a true emergency, your eligible expenses may be covered even if you had to go outside the HMO, as long as you follow the HMO’s rules. In this case, the provider will bill you directly. You then need to submit a claim form to be reimbursed. You will be reimbursed for part of the bill. To file a claim, follow the instructions on the claim form. If you received an Explanation of Benefits (EOB) statement from another health care company, be sure to include a copy with your claim form.