Depending on your plan, you may be eligible for additional coverage. Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis.
If your doctor is in the Cigna network, he or she will arrange for pre-certification. If you use an out-of-network doctor, you are responsible for making the arrangements.
Your plan materials will identify which procedures require pre-certification. Some plans may also provide out-of-network coverage for certain Urgent Care Services. See your plan documents for the details of your specific medical plan. Louis, Inc. Plans contain exclusions and limitations and may not be available in all areas. A Health Maintenance Organization is a network of doctors, hospitals and other health care providers who agree to provide care at a reduced rate.
To keep costs low, HMOs may require you to select a primary care physician sometimes called a primary care provider or PCP , who can refer you to specialists when needed.
An HMO plan will only pay for care from health care providers in the HMO network, except for emergency care, which may be covered out-of-network. Lab work, such as a blood draw, or a urine test, is also limited to one laboratory provider covered by the HMO network.
HMO plans are generally less expensive than PPO plans, with lower monthly payments, making them ideal if your favorite doctors are already in the network, or if you receive most of your care close to home.
Like an HMO, a Preferred Provider Organization is a network of doctors, hospitals and health care providers who agree to provide care at a certain rate. Unlike an HMO, you are not limited to providers who are in-network, though your copay or out-of-pocket cost for out-of-network visits may be higher than for in-network providers.
PPO plans typically require higher monthly payments in exchange for increased flexibility. With a PPO, you do not need to maintain a primary care physician, and can see a different doctor of your choice at any time, including specialists. PPOs can be a little more complicated. They often include deductibles, coinsurance, or copays. It all depends on your plan. If your plan is designed with copays only, this will work just like the HMO plans do.
You pay a set amount at the time of service. However, if you have a deductible with coinsurance, you will pay a certain percentage for services until your deductible is met. After your deductible is met, you may still need to make a copayment at the time of service. The range of covered services varies from one plan to the next. If a plan is offered on any Affordable Care Act ACA marketplace, it is required to cover preventive care such as checkups, physicals, or immunizations as well as emergency services and maternity care.
These services are known as the 10 essential benefits. With an HMO, patients do not need to file a claim because the insurance company pays the healthcare provider directly. Under a PPO, however, a patient must sometimes first pay out-of-network providers for any services received and then file a claim for reimbursement from their insurance company. Can receive at least limited coverage with an out-of-network provider. Can receive at least limited coverage for prescriptions at any pharmacy.
Provider or policyholder must file a claim to receive payment of benefits. Today, there are four different types of HMOs: Once HMOs were born, insurance companies saw an opportunity to provide patients with more flexibility while giving themselves better control over medical costs.
Hence, PPOs were introduced. PPOs rose to popularity among large corporations with many offices spread throughout the country, as a comprehensive PPO plan allows for greater geographical flexibility among the many employees. There are some additional insurance plans that operate in a similar fashion.
An EPO, or Exclusive Provider Organization , functions as an HMO but does not require all care to be funneled through a primary care physician, and no referrals are needed to see a specialist.
Just like an HMO, coverage is limited to only doctors within a network. And like a PPO, a POS allows for coverage outside of the network but generally with a referral from the primary care physician. A Fee for Service FFS plan, sometimes called an indemnity plan , allows for the most freedom and flexibility, but also comes with the highest price tag. FFS patients can choose physicians and specialists at will but face high out-of-pocket expenses and are not always covered for preventive services.
This type of plan may require you to pay for all services and then submit a claim to your insurance company for reimbursement. The tradeoff is a lower monthly premium. An HSA collects non-taxed contributions from your paycheck and uses that fund to pay for out-of-pocket health costs such as copays or coinsurance.
HMO stands for health maintenance organization. PPO stands for preferred provider organization. HMO plans. Which one is right for me? How can I choose or change my primary care physician?
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