Health Insurance Frequently Asked Questions (FAQ)

Below are the answers to several Health Insurance Frequently Asked Questions

What is a Primary Care Physician (PCP)?

A Primary Care Physician (PCP), interchangeably called a Primary Care Provider, is a doctor that practices general medicine.  A PCP is, in most cases, considered a family doctor who addresses general health issues related to specific patients. The job of a PCP is to stand as the first point of contact for any of its patient’s health issues. However, when a health issue is related to something outside a PCPs area of specialty, then they are expected to refer the patient to a specialist. Although most PCPs are doctors, they may also be nurse practitioners or assistant physicians.

What is an HMO?

HMO (Health Maintenance Organization) is a type of managed care health insurance whose primary goal is to ensure its members stay healthy. As the name implies, it is an organization that provides health insurance coverage to its members in exchange for a fee (monthly or annually). The organization provides medical aid to its members through doctors that are under its contract. HMOs offer lower premiums to these doctors since the doctors also benefit from the many patients directed to them by the HMOs.

What is a PPO?

A PPO (Preferred Provider Organization) is a form of medical care arrangement that is similar to the Health Maintenance Organization. This organization consists of a network of medical providers that provide special services to subscribed members (patients) at certain rates lower than what a regular medical organization would charge. A medical provider under a PPO is called a “Preferred Provider.”

What is a Special Enrollment Period?

A Special Enrollment Period (SEP) is a period under The Affordable Care Act (ACA) where an insured person is allowed to make health plan changes even though it’s not an open enrollment period. A special enrollment period is prompted by certain qualifying events, such as getting married, losing a job, or having children. Most Special Enrollment Periods last between 30 and 90 days before the insured has to wait for another Special Enrollment Period (or for the Annual Open Enrollment Period to begin) to make health plan changes.

What is a deductible?

A deductible is the amount of money an insured person must spend on their medical fees before their insurance company can begin paying for their medical fees. Once the insured meets their plan’s deductible, the insurance company will then become responsible for the medical fees, but the insured still has to pay their copayments under the insurance plan.

How do out-of-pocket maximums work?

The out-of-pocket is the maximum amount an insured person may personally pay for a covered medical service in a year. The out-of-pocket maximum differs depending on the insurance plan the insured has. Typically, an out-of-pocket maximum may include coinsurance, deductible, and copays, but does not include premium payments.

What is Tele Medicine?

Tele Medicine makes it possible to receive medical services without physically visiting a medical practice. Patients connect to healthcare professionals remotely, using technology such as videoconferencing, phone calls, emails, digital photos, and remote monitoring. It’s great for consultations and second opinions and saves patients lots of time and money.

What is Coinsurance?

Coinsurance is the percentage of covered health care costs that the insured individual pays, after the individual has met his or her health insurance deductible. For example, a doctor’s appointment could be $100 and your coinsurance is 15%.  If you haven’t met your deductible, you pay $100. If you have met your deductible, you pay 15%, or $15.

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