Question 1

What's the difference between an HMO and PPO health plan?

Accepted Answer

An HMO (Health Maintenance Organization) typically requires you to choose a primary care physician who coordinates your care and provides referrals to specialists within the network. HMOs generally have lower premiums but less flexibility. A PPO (Preferred Provider Organization) offers more flexibility in choosing healthcare providers, including seeing specialists without referrals, and provides some coverage for out-of-network care, but usually has higher premiums and out-of-pocket costs.

Question 2

What preventive services are typically covered at 100%?

Accepted Answer

Under the Affordable Care Act, most health insurance plans must cover preventive services without charging a copayment or coinsurance, even if you haven't met your yearly deductible. These typically include: annual wellness exams, vaccinations, various health screenings (like blood pressure, cholesterol, depression, etc.), many women's health services (including mammograms and birth control), and certain counseling services. The specific services covered may vary by plan and age group.

Question 3

What is an out-of-pocket maximum in health insurance?

Accepted Answer

An out-of-pocket maximum is the most you'll have to pay for covered services in a policy period (usually a year). This amount includes deductibles, copayments, and coinsurance, but not premiums. After you reach this limit, your health plan pays 100% of the costs of covered benefits for the rest of the policy period. This protects you from catastrophic medical expenses in case of serious illness or injury.

Question 4

How do prescription drug tiers work?

Accepted Answer

Prescription drug plans typically categorize medications into tiers, with different cost-sharing levels for each tier. Generally: Tier 1 includes generic drugs (lowest cost), Tier 2 includes preferred brand-name drugs (medium cost), Tier 3 includes non-preferred brand-name drugs (higher cost), and Tier 4 or specialty tiers include complex or very expensive medications (highest cost). Your copay or coinsurance amount increases as you move up the tiers.

Question 5

What happens if I use an out-of-network provider?

Accepted Answer

If you use an out-of-network provider: 1) You'll likely pay more, as your insurance may cover a smaller percentage of the cost or none at all. 2) You might have to pay the full cost upfront and submit a claim for reimbursement. 3) The provider can bill you for the difference between their charge and what your insurance pays (balance billing). 4) Any payments may not count toward your in-network deductible or out-of-pocket maximum. HMO plans typically provide no coverage for out-of-network care except in emergencies.

Healthcare Coverage

Open Enrollment Period: Your Guide to Choosing or Changing Health Insurance

How to Choose the Best Health Insurance Plan for You and Your Family

Medicare vs. Medicaid: Eligibility and Coverage Differences

Related Categories

Stay Updated on Healthcare Coverage

Frequently Asked Questions About Healthcare Coverage