Insurance FAQS

What is Managed Care:
An insurance program in which the member (patient) receives medical service in a coordinated manner to eliminate unnecessary medical procedures or services. In managed care health, the member seeks specialist or hospital care after prior approval of coverage by designated health care professionals, such as primary care physicians, utilization review nurses, or employer-designated professionals. The goal of managed care is to deliver cost-effective health care without sacrificing quality or access.

What is a PPO (Preferred Provider Organization):
A network of hospitals and physicians who agree to provide services at a discounted rate. The discount provides a savings to the insurance company and the patient. Members of PPOs may incur out-of-pocket expenses at a higher rate for covered services received outside the PPO provider network if the charge exceeds the PPO payment rate.
What is an HMO (Health Maintenance Organization):
An organized system of health care that assures the delivery of a complete range of health services to members who enroll voluntarily and pay a fixed, prepaid fee.

What is Point-of-Service:
A managed care product that offers the advantages of an HMO with the flexibility of a traditional health insurance plan. Members decide where to receive care when they need it - at the point-of-service.

What type of insurance is Indemnity:
Indemnity or "traditional" insurance is a type of plan that reimburses hospitals for covered charges for services performed, or insures for medical expenses incurred. Commonly referred to as an 80/20 plan. Indemnity plans are not PPO driven and members can choose their providers without penalty.

What is a Deductible:
The portion of a member's health care expenses that must be met (paid) by the member before any insurance coverage applies, before payment is made by the insurance company.  Deductibles are usually applied annually.  If deductibles have not been met, they may be requested at the time of service.

What does Co-insurance mean:
The portion of charges that patients are responsible for paying according to the terms of their insurance policy. This is the portion that may be requested at the time of service.

What is a Copayment (Copay):
A fixed dollar amount made by a member (patient) at the point-of-service. Examples: A typical copayment for a physician's office visit may be 15, 25, or 30 dollars.