Q) What types of health plans are available to me?

Health insurance plans usually are described as either indemnity (fee-for-service) or managed care. Indemnity and managed care plans differ in their basic approach. Put broadly, the major differences concern choice of providers, out-of-pocket costs for covered services, and how bills are paid. Usually, indemnity plans offer more choice of doctors (including specialists, such as cardiologists and surgeons), hospitals, and other health care providers than managed care plans.

Indemnity plans pay their share of the costs of a service only after they receive a bill. Managed care plans have agreements with certain doctors, hospitals, and health care providers to give a range of services to plan members at reduced cost. In general, you will have less paperwork and lower out-of-pocket costs if you select a managed care-type plan and a broader choice of health care providers if you select an indemnity-type plan.
Besides indemnity plans, there are three basic types of managed care plans: PPOs, HMOs, and POS plans.

Q) 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.

Q) 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.

Q) What is a provider?

A provider is a hospital, health care facility, physician or other medical professional that provides health care services.

Q) 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 health care system. Also known as a primary care provider, personal care physician, or personal care provider.

Q) What is an office visit copayment?

An office visit copayment is a fixed dollar amount or a percentage that you pay for each doctor visit. 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.

Q) 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.

Q) 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 your receive from outside their network; however, there are exception 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.