Credit Basics for Insurance

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

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.

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.

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.