FAQ's (frequently asked questions):
What's the difference between an HMO and PPO plan?
The most significant difference is HOW you access care.
With an HMO plan, you choose a personal physician with a low office visit copay who will manage your care and refer you to a specialist, usually within the same medical group, belonging to the HMO network. You and all family members covered by the plan must live or work in a specific area served by your personal physician. Access to care outside of California is available but is only for true emergency situations and some restrictions apply. There are no out of network benefits except for emergency situations. Generally monthly premium rates are higher so that your copay costs are lower whenever you access care throughout the year.
With a PPO plan, you may visit any licensed doctor within the PPO network. Access to care is nationwide and referrals are not required from your personal physician. You may see a specialist at any time in the preferred network. Seeing a physician out of network will cost you more. Generally PPO plans offer lower monthly premium rates with higher out of pocket costs when you access care during the year. Many coverage options with varying deductibles, many plans now offer no maternity coverage to reduce monthly premiums.
How does health insurance work?
You pay a monthly premium (rate) for health coverage and in return, the insurance company (carrier) pays for the majority of your medical costs once your medical deductible has been satisfied. You may also pay a share of the cost for the care you receive called coinsurance. The size of your share depends on the specific plan, but in general, the higher the plan's monthly premium rate, the smaller the share of medical costs you pay before reaching your "out-of-pocket" maximum. A simple example: a serious accident costing $140,000 without insurance. With insurance coverage within the network, this is reduced by $133,000 and your cost including premiums would be approximately $7,000. Since the doctors and hospitals are in the network, they have agreed to bill specific fees for their services called "allowable amounts." We, at MyBenefits2, can help protect you from the high costs you would be subject to without coverage and avoid possible bankruptcy.
How do deductibles work?
If your individual health plan has a deductible, you must pay this amount each year before the insurance carrier makes payments towards covered services. Depending on your plan, some services, such as preventive care, may be covered by the carrier before you have to meet the deductible. Meeting family deductibles is different and how it is met varies with each plan. Sometimes all family members must reach the deductible collectively, other plans will allow one member to reach the individual deductible to access services first until the other members meet the rest of the family deductible. It just depends, ask us.
If you have a question that is not answered here, please send us an email or call 619.563.4052.
Office: 619.563.4052 Email: firstname.lastname@example.org
P.O. Box 635035, San Diego, CA 92163