Know Your Health Plan

What kind of plan is it?

HMO: Requires a PCP (Primary Care Physician) and referral authorizations for specialists. Specialists must be in the plan’s limited network, otherwise you may have to pay their costs yourself. HMOs often have lower premiums and deductibles.

PPO: No PCP or referral authorizations required. PPOs typically have wider networks of specialists, with more flexibility, and cover more out-of-network costs than HMOs (in-network specialists will cost less than out-of-network). PPOs typically have higher premiums and deductibles.

POS: Requires a PCP, and will cover more out-of-network costs for specialists if the PCP authorizes a referral.

What do you pay out of pocket?

Premium: The fixed amount you pay your plan (or employer) monthly. It will be bigger or smaller depending on the kind of plan and the size of deductibles.

Co-pay: A flat fee you pay us for each non-preventive visit, at the visit.

Deductible: An amount you pay us (up to an annual maximum) before your plan begins to pay claims. May apply to all of our charges, or just lab fees or certain kinds of visits. If you have a deductible and you’d like to know the cost of a visit in advance, it’s up to you to ask us.

Coinsurance: A percentage of your total medical costs after you reach your deductible.

Does it require prior authorizations?

Some plans require prior authorizations for certain procedures or medications. They are different from referral authorizations, which apply to specialists. They usually take longer to process than referrals.

When does it cover the next well child visit?

By the date of the last physical? Or by the calendar year? Most Blue Cross, Harvard Pilgrim, and United plans cover well visits any time during the next calendar year. To be sure, call your plan. You may be responsible for charges if a visit is not covered.