Deciphering the Insurance Maze
After working
with cancer patients and their insurance companies
for years, no one knows better than CCNC that
understanding insurance can be difficult. So
here you can find information on various plans
and what the jargon means. We work with a variety
of managed healthcare plans and insurance companies.
To find out if we contract with your insurance
company, please view the Accepted Insurance Plans
to the right of your screen or contact us.
Health Plans
Health Maintenance Organizations
(HMOs): HMOs are organized systems for providing health
care in
a geographic area. They have a set of basic and supplemental
preventative and treatment services; members generally
select a primary care physician (PCP) who is responsible
for making all referrals to specialists. HMOs offer
no "out of network" benefits and have low
out-of-pocket (co-pay) expenses.
Indemnity Plans: Indemnity or traditional insurance
is not considered "managed care." In indemnity
plans the member chooses his or her own providers.
Oversight of care by the health plan is minimal.
The member's out-of-pocket payment is generally a
percentage of the provider's usual and customary
fee schedule.
Managed Care: A broad term
that describes programs designed to manage the cost
and quality of health
care. Ideally, managed care brings about a comprehensive
healthcare system where patients receive the care
they need, including preventative care when they
need it. The plans vary from restrictive provider
lists and low out-of-pocket amounts to fairly open
provider lists and high out-of-pocket amounts.
Medicaid: The State health insurance program for
low-income individuals, the indigent and elderly.
Many states are introducing Medicaid HMOs for this
population.
Medicare: The federal health insurance program for
older Americans and eligible disabled individuals.
Medicare HMOs are beginning to be offered in some
areas of the country.
Point of Service (POS): POS plans build on the HMO
concept. However, if a member chooses to seek a specialist
directly, without a referral from their PCP, or seeks
an "out-of-network" provider, they will
have coverage with a higher out-of-pocket (co-insurance)
amount.
Preferred Provider Organization
(PPO): PPOs generally
provide "in-network" and "out-of-network" benefits
and do not require a PCP referral to see a specialist.
The amount the member must pay out of pocket is less
when using an "in-network" provider.
Common Managed Care/ Insurance Terms
Co-payment: A flat fee paid out of pocket for medical
services, usually at the time the service is rendered.
Usually applies to physician office visits, prescriptions,
emergency or hospital services.
Co-insurance: Co-insurance, like co-payments, is
a common form of member cost-sharing, typically applied
as percentage of applicable costs after the deductible
requirements are met. With traditional non-managed
care plans, the percentage is based upon provider
charges, sometimes up to a maximum allowable amount
per service. In managed care plans, the percentage
can be based upon provider contract rates.
Deductible: The amount of medical expense a person
must pay each year from his/her own pocket before
the health plan will make payment.
Gatekeeper: When a primary
care physician, the "gatekeeper,"
serves as the patient's initial contact for medical
care and referrals.
Out-of-Network Benefit: PPOs and HMO Point of Service
plans contain an out-of-network benefit tier that
is different from benefit coverage for network services.
In PPO plans cost-sharing requirements may exist
that are somewhat "hidden" in the process.
For example, a number of PPO plans indicate a percentage
co-insurance requirement for out-of-network, but
also limit the benefit to a maximum allowable based
upon average contract rates. This means the member
must pay a percentage co-insurance based on the maximum
allowable, plus the entire amount that exceeds the
maximum.
Primary Care Physician (PCP): A PCP is a physician
designated as responsible for providing specific
primary care services. This includes evaluation and
treatment of a patient, including decisions regarding
referral for specialty care. PCPs are generally in
family practice, general practice, general internal
medicine, pediatrics and sometimes obstetrics and
gynecology. Under the HMO health plan model, the
PCP may also be considered the gatekeeper.
While these terms are not comprehensive nor universally
accepted definitions, they are meant to assist the
reader to understand concepts, programs, services
and information relating to managed healthcare finance
and delivery.
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