The ABC’s of health insurance
HMO, PCP, PPO, POS — feel like you’re wading through alphabet soup? Read on for translations of common terms.
• Health maintenance organizations (HMO) require you to choose a primary care physician (PCP), who coordinates all of your care, including visits to specialists.
• Preferred provider organizations (PPO) let you make your own choices from a network of preferred providers (in some plans, you can pay a higher fee for out-of-network care) and may not require you to have a primary care physician.
• Point-of-service plans (POS) let you choose between receiving care from participating providers (you’ll be reimbursed more for this), or non-participating providers(you’ll be reimbursed less for this).
Some plans offer lower premiums (monthly payments) in exchange for a higher yearly deductible (the amount you must pay personally before insurance provides any coverage). Some plans require co-pays, a set fee you pay for health care visits or medications. Others ask you to pay co-insurance, which means you’re responsible for a portion (20 percent, for example) of eligible expenses charged by a provider or the amount the insurer agrees to pay for specific services.
Many plans require preauthorization or precertification for certain services, such as surgery or visits to a specialist. Some pick up the tab on preventive care services, such as flu shots, cholesterol tests, or colonoscopy. Most have formularies that list pre-approved, commonly prescribed drugs.
Who’s in charge here?
It is your responsibility to get the appropriate screenings at the appropriate time based on your age, gender, race, risk factors and family history. If your doctor does not offer the tests, ask for them. You’re the one who ultimately pays — in poor health.
*Frequency and starting age will differ by risk factors. For instance, if you have prostate cancer in your family, you will probably start screening at age 40 or 45.
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Sources: American Cancer Society, American Heart Association,