Insurance Basics

  1. What is a provider?

A provider is a hospital, healthcare facility, physician or other medical professional that provides healthcare services.

2. What is a Primary Care Physician (PCP)?

A physician or other medical professional who serves as a group member’s first contact with a plan’s healthcare system. Also known as a primary care provider, personal care physician, or personal care provider.

3. What is a PPO?

A PPO is a Preferred Provider Organization. As a member of a PPO, you can use the doctors and hospitals within the PPO network or go outside of the network for care. You do not need a referral to see a specialist.

  • If you obtain care from a medical provider outside of the PPO network, you will pay more for the service. For example, a PPO might pay 90 percent of the cost for a visit with an in-network doctor but only 70 percent of the cost for a visit to a non-network doctor.
  • You will typically pay a copayment for each visit/service. These copayments are typically higher than an HMO copayment but not always.
  • You will usually be responsible for paying an annual deductible.

If you join a PPO, you should find you have more flexibility than with an HMO, but your total out of pocket costs are likely to be somewhat higher.

4. What is an HMO?

An HMO is a Health Maintenance Organization. As a member of an HMO, you select a primary care physician from a list of doctors in that HMO’s network. Your primary care physician will be the first medical provider you call or see for a medical condition. He or she will make any needed referrals to a medical specialist. Typically, these specialists will be part of the HMO network.

  • If you obtain care without your primary care physician’s referral or obtain care from a non-network member, you may be responsible for paying the entire bill (with exceptions for emergency care).
  • With some HMOs, you pay nothing when you visit in-network doctors. With other HMOs there may be a small copayment for the visit or service.
  • With most HMOs you will not be responsible for paying a deductible.

If you join an HMO, you should find that you have few out-of-pocket expenses for medical care — as long as you use doctors or hospitals that are part of the HMO.

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