1
What does HMO stand for?
Health Maintenance Organization
Can members receive care from both in-network and out-of-network providers under Personal Choice PPO?
Yes, they can
What are some limitations of an HMO plan?
Providers network
Members must select a PCP in a Personal Choice EPO plan. True/False
How does an EPO provide more flexibility than an HMO?
HMO Members can visit any in-network specialist without a referral. True/False
False
What does EPO stand for?
Exclusive Provider Organization
The Personal Choice EPO generally emphasizes in-network care.
True
The BlueCard PPO network provides nationwide in-network access. True/False
True
Why is it important for HMO and EPO members to verify whether a provider is in-network before receiving care?
To confirm if the service can be cover or not.
Compare the referral requirements of an HMO, PPO, and EPO.
Referral from PCP needed for HMO Plans
No referral needed for EPO and PPO
A member wants to see a cardiologist without requesting a referral from their PCP first. Can they do so under a Personal Choice PPO plan?
Yes, they can
How would you explain the difference between in-network and out-of-network coverage?
In-network = Doctors, hospitals, and providers that have an agreement with your health insurance company.
Out-of-network = Doctors, hospitals, and providers that do not have an agreement with your health insurance company.
A HMO member receives routine care from an out-of-network doctor. Is it covered by the insurance?
No, is not covered
How would you compare a Keystone HMO plan to a PPO plan when discussing flexibility and costs?
Keystone HMO = Lower Cost, Less Flexibility (INN providers, Referral needed, PCP required)
PPO = Higher Cost, More Flexibility (ONN/INN providers, No referral needed, no PCP required)
Is the amount of money a member pays to their health insurance company for covered health care services.
Premium
Is also referred to as out-of-pocket costs. Cost sharing consists of copayments, deductibles, and coinsurance.
Cost sharing
A type of cost-sharing where the member pays a flat-dollar amount such as a $5 or $10 copayment each time a covered service is provided.
Copay/Copayment
A percentage of the service fee that is the member’s responsibility.
Coinsurance
A flat amount the member must pay before the insurer makes any benefit payment.
Deductible