HMO
What does HMO stand for?
What is Health Maintenance Organization?
What does PPO stand for?
What is Preferred Provider Organization?
This type of plan only covers services provided by in-network providers. except in emergencies.
What is an EPO
This type of plan combines features of HMO and PPO plans.
What is a POS plan?
This is the term for California’s version of the Medicaid program.
What is Medi-Cal?
This is the type of doctor you must choose when enrolling in an HMO plan.
What is a Primary Care Physician (PCP)
This feature allows PPO members to see specialists without this requirement.
What is no referral needed?
What does EPO stand for?
What does POS stand for?
What is Point of Service
This part of Medicare covers hospital inpatient care.
What is Medicare Part A?
To see a specialist under an HMO, this is usually required.
What is a referral from your PCP?
This is typically higher in PPO plans compared to HMO plans.
What are premiums and out-of-pocket costs?
This approval is commonly required in EPO plans before accessing high-cost or specialized medical services.
What is pre-authorization or pre-certification?
This benefit of POS plans allows patients to decide how they want to receive care at the time of their visit.
What is the option to use HMO or PPO benefits?
This plan provides coverage for active-duty military members and their
What is TRICARE?
This is the term for services received outside of the HMO network that are not covered.
What are out-of-network services?
This is one of the main advantages of PPO plans over HMO plans.
This is the main limitation of EPO plans when compared to PPO plans.
What is no out-of-network coverage?
This must be used if the POS plan includes a Medical Group/IPA but the group is not listed in EPIC.
What is the POS plan code with 'GENERIC IPA'?
This government insurance covers children with serious chronic illnesses in California.
What is California Children’s Services (CCS)?
This situation can lead to denial of an HMO claim even if the patient received necessary care.
What is lack of referral or prior authorization?
This term refers to the portion of healthcare costs that a PPO member must pay after the deductible and before reaching the out-of-pocket maximum.
What is coinsurance?
Before scheduling services, EPO members are expected to complete this important step to ensure coverage.
What is confirm the provider is in-network and obtain any required authorizations?
True or False: A patient can switch to HMO benefits after using their PPO coverage for their first visit at City of Hope.
What is False? The HMO must authorize the initial consultation to be billed under HMO benefits.
This program is a managed care option combining Medicare and Medi-Cal into a single plan.
What is Cal MediConnect or a Dual Plan?