Medical Terms / Acronyms

 

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 may 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 a 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 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 if you use the doctors or hospitals that are part of the HMO.


What is a provider?

 

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.


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 $250 deductible, you will pay the first $250 of you medical expenses before your health plan begins paying the expenses. Only expenses for covered services apply towards the deductible.


What is the difference between an in-network and an out-of-network medical provider?

 

An in-network medical provider is within the list of providers chosen by a particular health carrier. Out-of-network providers are providers who are not included on this list. If you visit a physician within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network physician.

 

What is a Co-Payment?

 

A fixed dollar amount that the insured pays when a covered medical service is received. For example, a doctor’s office visit could have a copayment of $30 per visit.

 

What is Co-Insurance?

 

A stated percentage of medical expenses that the insured has to pay after the deductible amount, if any. It generally has a cap dollar amount, which can be different on each policy. An example of coinsurance: 25% of covered medical expenses up to a $3500 maximum.

 

Where can I go if I have COBRA questions? CLICK HERE

 

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