This is the group of Doctors, Hospitals and Clinics (Providers) that have negotiated with an insurance company to provide their services at a reduced rate as part of being in that network. There are four types of networks that should be considered when choosing a health benefit plan.
POS (Point of Service):
This is the smallest of all the networks. It requires you to see a primary care provider in the network to receive benefits. You would also be required to have a referral from your primary care doctor in order to see a specialist.
EPO (Exclusive Provider Organization):
This is also typically a small network and requires you to see providers that are only in that network to receive any benefits. In addition, if you need to see a specialist you would need to see your Primary Care Physician first to be referred to a specialist.
HMO (Health Maintenance Organization):
This is a larger network however it does require you to see providers that are in that network to receive benefits. Likewise, if you need to see a specialist you would need to see your Primary Care Physician first to be referred to a specialist.
PPO (Preferred Provider Organization):
This is the largest network of providers. While you would need to be In Network to receive the reduced network rate you will have more freedom in your choices. If you need to see a specialist, you would not need a referral and can contact that specialist directly to set an appointment.
This is the amount you pay per month for your health benefits.
On many insurance plans you will have to pay a certain amount out of pocket (in addition to the premium) before the insurance benefits start to apply. As an example, if you have a $5,000 deductible, you may need to pay that $5,000 before the insurance benefits start.
This the amount you pay directly when going to the Doctor, Clinic or Hospital. Typically, the amount you pay for the co-pay does not count toward your deductible.
This is the amount that the insurance company pays, and you pay, based on a percentage, for provider services. For example, if the co-insurance is 70% / 30% then the insurance company will pay 70% and you would pay 30% of the amount that remains due after any network reduced rates. On some insurance plans co-insurance only takes effect after the deductible has been met.
Out of Pocket Maximum:
This is the total amount you would be paying out of pocket before many insurance policies will cover 100% of the costs.
First Dollar Benefits:
This refers to insurance policies that will immediately begin providing benefits without having to meet any deductible. This means that as soon as the policy is in place the benefits from the insurance company would be available.
These plans typically relate to the ACA (Affordable Care Act) / “Obamacare” plans that are available for everyone (during open enrollment periods or special circumstances). The premium cost and deductible is based on household income and, depending on what state you live in, may limit the network coverage available.
These plans are underwritten full coverage plans that are typically based on your health situation. They often can have lower premiums and broader network coverage.
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