More Facts for you to Know and Share

Another Friday Facts message is on the insurance networks. There are 2 basic network setups available - HMO and PPO. An HMO is a Health Managed Organization. It is a limited network of doctors and facilities that your insurance company will pay claims for you to see. You are usually required to declare a primary care physician (PCP) up front and go through that physician for all care and referrals. (An EPO is a form of HMO that usually doesn't require you to get a referral from your PCP to see a specialist.) A PPO is a Preferred Provider Organization - These groups are larger than HMO networks and also allow coverage for doctors that are not in the network. Be careful though - out of network doctors usually have at least double the deductible and max out of pocket as in network doctors. You can also owe balance billed amounts if the out of network doctor feels that the amount the insurer pays is insufficient. [Never assume that just because your doctor refers you to someone or someplace that they are in network - take the time to double check for yourself or it could cost you!]

If you are in an life threatening emergency situation - go to the nearest facility - you will be covered. Not sure if your issue is life threatening? Try calling your insurers nurse hotline first - they will tell you if they think you should go to the ER or if it is safe not to.

I've heard some people compare an HSA plan to a PPO - this is apples and oranges. An HSA plan means you are qualified to have a Health Savings Account (topic for a future Friday) and you will have no "first dollar coverage" other than your annual exams. An HSA qualified plan can be with an HMO, EPO or PPO network.

Right now in Texas there are NO PPO network ACA qualified Major Medical plans for individuals - business groups only. If you are offered a plan with a PPO network it is a healthshare, indemnity or short term medical plan (oh look - there's another Friday's discussion). The insurers have chosen to eliminate the PPO networks for individual plans because a smaller group of doctors is less expensive for them to deal with. In a recent quote for a very small business I was running the exact same plan was $152/m/person higher with the PPO network as the HMO. This can really make you think about who is in a network and can you work within the smaller HMO option.

If you have topics you would like me to discuss in a future Friday Facts article - let me know. If you have questions about your coverage options - Let's talk.