When it comes to choosing a Health Insurance Plan, it is great to have options. However, having options in the Health Insurance market can quickly become overwhelming. Two types of health plans that shoppers often find themselves choosing between are HMO and PPO Plans. One of our most commonly asked questions from Health Plan shoppers is: “What is the difference between a HMO vs PPO plan?” There are many terms that are used to describe these types of health plans, and understanding them is key when determining which plan is right for you.

Health Maintenance Organization (HMOs)

The term HMO stands for Health Maintenance Organization. HMOs are regarded as a managed health care system, which provide prepaid medical services with little out of pocket expense. With an HMO plan, the subscriber will be required to see a Primary Care Physician (PCP) that is in network with their HMO plan. These plans have networks of medical providers, and subscribers must seek treatment from these providers. There are no out of network benefits under an HMO plan. Some HMO plans may also require your Primary Care Physician give you a referral in order to see a specialist. Because these types of plans have more restrictive networks, subscribers will generally have lower premiums and low deductibles under these plans.

Preferred Provider Organizations (PPOs)

The term PPO stands for Preferred Provider Organization. These plans are an arrangement under which a group of independent doctors and hospitals become preferred providers in an area. PPO plans offer more flexibility and choices when it comes to choosing your doctor or hospital. Like HMOs, PPOs also have a network of providers. However, there are fewer restrictions on seeing providers who are not in network. Under a PPO plan, you will also usually have the benefit of seeing a specialist without a referral from your Primary Care Physician. Because PPO plans are more flexible, premiums tend to be higher, and it is common to have a deductible.

Point of Service (POSs)

Point of Service Plans (POS) are a hybrid plan that combine features of PPO and HMO plans. These plans are designed so the member can choose (at the point of service) which part of the plan they would like to utilize. If the subscriber stays in network with this plan, they will have HMO benefits. If the member sees an out of network provider, they will be responsible for the out of network rates. Blue Cross Blue Shield of North Carolina offers a variety of Point of Service health plans. CLICK HERE to generate a custom quote and discover your plan options.

What do these plans have in common?

HMO’s, PPO’s and POS plans all have provider networks. A network refers to the list of doctors, hospitals, labs, and other providers that are contracted with the health plan. The difference in these plans network options is the size of the network, and whether or not the plan offers out of network benefits. Each of these types of plans also offer coverage for emergency services both in and out of network.

At NC Health Plans, we understand that making decisions within the Health Insurance market can be confusing. Blue Cross Blue Shield of North Carolina offers a variety of health plans for both under 65 and Medicare shoppers. Give us a call to speak with one of our professional agents and discover what health plan will work best for you or your family.

For more information on North Carolina Health Insurance coverage, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our experienced and professional agents.

Health insurance can seem a bit overwhelming, so we thought a few terms defined might be helpful as you consider your current policy or look to purchase a new one!

Coinsurance is the percentage of covered medical expenses that you pay after you’ve met your deductible. Coinsurance is usually listed as a percentage. For example, if your plan lists coinsurance at 20% of covered medical expenses after you’ve met your deductible, then the plan pays 80% of covered services, and you pay 20% until you reach your coinsurance maximum.Coinsurance maximum The coinsurance maximum is the total amount of coinsurance that you’re required to pay for covered medical services in a plan year. Once you reach the coinsurance maximum, your plan usually covers 100% of all covered services for the remainder of the benefit period. Under a traditional health plan, you would continue to pay any copayments for covered services, such as office visits or prescription drugs. Under a high-deductible health plan, your covered medical services would be paid 100%.

Out-of-pocket maximum

Your out-of-pocket maximum is the maximum amount you would be required to pay in a plan year for covered medical expenses. With a high-deductible health plan, this amount is usually the total of your deductible plus your coinsurance maximum. Knowing the definitions of some common terms associated with health insurance may help you make better decisions about choosing a plan that’s right for you.

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Many BCBSNC applicants ask the question…. What is coinsurance?  BCBSNC defines coinsurance as “the percentage of the allowed amounts for covered services that BCBSNC will pay after you meet your deductible.”  In other words, it is the percent that the insurance company is responsible for paying towards your medical bills.  When does coinsurance come into play?  When you have to go into the hospital, have diagnostic testing such as MRIs, CAT Scans, or x-rays, or if you have surgery in a free standing surgery center. 

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

Health insurance companies use historical data and analysis to predict the medical expenses for any given group of individuals (usually a company’s employees). The premiums they charge are based on the amount of claims they’ve paid in the past and what they expect future claims to cost. When insurers pay out more in claims than they receive in premiums and when future services are predicted to cost more, premiums go up.

As consumers, we are demanding more medical services than ever before. And the cost of these services is going up. These increased costs are passed on to employers in the form of increased premiums. Insurance companies work with employers to adjust services offered, as well as co-payments and deductibles, to minimize the impact of rising costs.

Take time to understand your health plan — it can help save healthcare dollars for you and for all Americans. For example, many health plans offer a reduced co-pay if you choose FDA-approved generic prescription drugs, so you pay less. Because the average total cost of a generic drug is three times less than the brand name, it helps keep costs down in your health plan.

Understanding the basics of how health insurance works and how to make the most of your own health plan can help keep healthcare affordable for everyone.

The content of this post is from BlueCross BlueShield Association’s article “Coverage Basics: How Health Insurance Works”

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

Blue Points

Earn prizes for taking an active role in your health.
Physical activity can help reduce the risk of cancer, heart disease, diabetes and other health conditions. That’s why we created Blue PointsSM, our physical activity and wellness incentive program available exclusively for BCBSNC members.

Just 30 minutes a day of physical activity or participation in wellness activities earns points toward prizes like electronics, sports equipment, clothing and more!* Collect points and select prizes from our four Blue Points prize levels (B, L, U, and E). Special prizes are available for children ages 6 – 12 through Blue Points for KidsSM.

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How do health insurance deductibles and out-of-pocket amounts work?

A deductible is the amount you must pay before the insurance company begins to pay any policy benefits. This is usually an annual amount per insured person, per calendar year.  Although typically there will be a maximum amount of deductibles you will have to pay per family in any given year.  For example, if your “per person” deductible is $500, and you have five people in your family covered under your health insurance, the maximum “family” deductible is usually three times the individual deductible or $1500.00 in this example.  Once three individuals have paid the $500 deductible, no more deductibles will apply to any member of the family for the remainder of the year.  (more…)

HIPAA: A Federal law passed in 1996 that allows persons to qualify immediately for comparable health insurance coverage when they change their employment or relationships. It also creates the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care. Full name is “The Health Insurance Portability and Accountability Act of 1996.”

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

Credit for Prior Coverage: This is something that may or may not apply when you switch employers or insurance plans. A pre-existing condition waiting period met under while you were under an employer’s (qualifying) coverage can be honored by your new plan, if any interruption in the coverage between the two plans meets state guidelines.  Letters of creditable coverage are sent from previous insurance companies to the previously insured.  Newly enrolled customers for BCBSNC can fax their letters of creditable coverage to 919-765-7149.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

Network: A group of doctors, hospitals and other health care providers contracted to provide services to insurance companies customers for less than their usual fees. Provider networks can cover a large geographic market or a wide range of health care services. Insured individuals typically pay less for using a network provider.

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Explanation of Benefits: The insurance company’s written explanation to a claim, showing what they paid and what the client must pay. Sometimes accompanied by a benefits check.

COBRA: Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For more information, visit the Department of Labor.

Waiting Period

This is the time one would have to wait until certain health insurance coverages are available.

Lifetime Maximum

This is the most amount of money the health insurance policy will pay for the entire life. Pay attention to individual lifetime maximums and family lifetime maximums as they can be different.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.

Pre-Existing Conditions

A pre-existing condition is a medical condition diagnosed or treated before joining a new plan. In the past, health care given for a pre-existing condition often has not been covered for someone who joins a new plan until after a waiting period.

Under the law, most of which goes into effect on July 1, 1997, a pre-existing condition will be covered without a waiting period when you join a new group plan if you have been insured the previous 12 months. This means that if you remain insured for 12 months or more, you will be able to go from one job to another, and your pre-existing condition will be covered. without additional waiting periods. even if you have a chronic illness.If you have a pre-existing condition and have not been insured the previous 12 months before joining a new plan, the longest you will have to wait before you are covered for that condition is 12 months.

To find out how this new law affects you, check with either your employer benefits office or your health plan.

For more information on health insurance coverage in North Carolina, please visit our website at www.nchealthplans.com or call our toll free number 888-765-5400 and speak with one of our qualified agents.  Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC).  You may qualify for a 15% healthy lifestyle discount if you are in excellent health.  Call us for details.