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HEALTH INSURANCE FREQUENTLY ASKED QUESTIONS
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Click on a question to jump to the answer.
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What are the differences between HMO, POS, PPO & Indemnity plans?
What is the difference between a copayment and coinsurance?
How do I meet a deductible?
What is COBRA?
What is HIPAA?
What do I do if I have a problem with a claim?
What do I do if I have trouble accessing care?
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What are the differences between HMO, POS, PPO & Indemnity plans?
HMO (Health Maintenance Organization) plans only cover you when you use a healthcare provider that is contracted (In-Network). You pay a copayment for service rendered by a contracted provider.
POS (Point Of Service) works similarly to an HMO, however, allows use of a non-contracted provider (Out-of-Network) or a contracted provider. You pay a deductible and coinsurance for services by a non-contracted provider. You pay a copayment for services rendered by a contracted provider.
PPO (Preferred Provider Organization) allows you to see any provider of choice. However, benefits are better when you use a contracted provider. Typically, you pay a lower deductible and coinsurance for contracted providers than for non-contracted providers. A PPO plan may also have copayments for office visits to a contracted provider.
Indemnity plans also allow you to see any provider of choice. You pay the same deductible and coinsurance no matter who the provider of choice is, as long as the provider and service are considered covered benefits.
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What is the difference between a copayment and coinsurance?
Copayments are a flat fee paid by the patient for services rendered by a contracted provider. The patient normally does not have to pay any more than the copayment since the insurance company covers 100% of the balance. The copayment goes directly to the provider and the insurance company does not receive any part of the copayment.
Coinsurance is a percentage of the charge for service rendered that is to be paid by the patient. For example: A plan's coinsurance may require you to pay 20% of the charge and the insurance company pays 80%. Plans with coinsurance usually require you to first meet a deductible before the insurance company will pay their share of the coinsurance.
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How do I meet a deductible?
Deductible amounts are credited when the insurance company processes your claim. Therefore, the insurance company must process all charges. You cannot meet a deductible by giving the healthcare provider, or the insurance company, a check or cash. The insurance company will give you a copy of how the claim was processed (referred to as an Explanation of Benefits or EOB) indicating how much of the deductible has been met to date.
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What is COBRA?
COBRA (Consolidated Omnibus Budget Reconciliation Act), passed in 1996, gives you the right to continue group health benefits if you are an employee losing benefits due to a reduction in work hours or termination of employment. If this is the case, you can continue coverage for up to 18 months. If you are a dependent losing group health benefits due to legal separation, divorce or age limitations, you may continue coverage for up to 36 months. COBRA is a complicated process so let us help you by contacting us for more details.
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What is HIPAA?
HIPAA (Health Insurance Portability and Accountability Act of 1996) gives you the right of guaranteed individual coverage plus credit towards pre-existing waiting periods when you lose group medical coverage. How HIPAA works is complicated so let us help you by contacting us for more details.
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What do I do if I have a problem with a claim?
We have trained customer service representatives who are dedicated to helping you with claim issues. Contact us for assistance!
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What do I do if I have trouble accessing care?
We have trained customer service representatives who are dedicated to helping you access care. Contact us for assistance!
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