Learn the Basics
As you look at our plans or get a quote, you may see concepts and terms that are unfamiliar. To help you make smarter healthcare decisions, we've put together a list of common concepts and terms.
HMO: HMO stands for Health Maintenance Organization. An HMO provides comprehensive health care by network physicians to enrolled individuals and families in a particular geographic area. It is financed by fixed periodic payments determined in advance. In an HMO, you need to access care through a designated Personal Physician.
PPO: PPO stands for Preferred Provider Organization. The members receive coverage by using doctors and hospitals within the PPO network, or they can pay more to have the freedom to go outside of the network for care. In our PPO plans, contracted doctors and hospitals are called preferred providers.
Personal physicians (applies to HMO plans): Providers who have contracted with the insurance company to provide primary care to HMO members and to refer, authorize, supervise and coordinate the provision of all care to members.
Preferred providers (applies to PPO plans): Providers who have contracted with the insurance company to be part of the preferred provider network. Preferred providers render covered services to PPO plan members at contracted rates (allowable amount).
Non-preferred providers (applies to PPO plans): Providers who have not contracted with the insurance company to be part of the preferred provider network. You are responsible for the difference between the amount the non-preferred provider bills and any amount that the insurance company pays. Some PPO plan benefits, such as certain preventive care and office visits, are not covered when accessed from these providers.
Deductible: The initial amount you pay in a calendar year for particular covered services before the insurance company pays.
Copayment: The fixed amount and/or percentage amount you pay for covered services after meeting any applicable plan deductible.
Copayment/coinsurance maximum: The limit on the amount you pay for certain covered services during a calendar year. Once the maximum is reached the insurance company will pay 100% of the allowable amount for all applicable covered services, up to specified maximums for the rest of the calendar year. Certain PPO plan covered services, such as office visits, generally do not count towards these maximums, and continue to be your responsibility.
Coinsurance: The percentage of the allowable amount or billed charges that you pay for covered services after meeting any applicable plan deductible.
Pre-existing condition: An illness, injury or condition for which medical advice, diagnosis, care or treatment was recommended or received from a licensed health practitioner during the six months prior to the plan effective date.
Preventive care: Primary preventive medical services provided by a physician for the early detection of disease when no symptoms are present.
Waivered condition: A condition that is excluded from coverage for charges and expenses incurred six months from the effective date of coverage. A waivered condition only applies to a condition for which medical advice, diagnosis, care or treatment (including prescription drugs) was recommended or received from a licensed health practitioner during the six months immediately preceding the effective date of coverage.
