Health care lingo can be an alphabet soup of terminology. There is one set of terms that it is important to be familiar with so you know how your plan works - your health plan's type. Knowing the mechanics of your plan will help you navigate the complexities of health plan benefits and avoid unexpected and costly out-of-pocket charges.
HMO (Health Maintenance Organization): If you are in an HMO, you must use network providers - doctors, hospitals and other health care providers - that participate in the plan. The only exception is for emergency care. An HMO requires the selection of a Primary Care Physician (PCP) to manage your care. Referrals are usually needed from your PCP to see a specialist, who must also be in the network. The GIC's HMOs include Fallon Health Direct Care and Select Care, Harvard Pilgrim Primary Choice Plan, Health New England, Neighborhood Health Plan, and the following Medicare Plans: Fallon Senior Plan, Health New England MedPlus, Tufts Health Plan Medicare Complement and Tufts Health Plan Medicare Preferred.
EPO (Exclusive Provider Organization): Similar to an HMO, with an EPO you must use network providers - doctors, hospitals and other health care providers - that participate in the plan. The only exception is for emergency care. Unlike an HMO, you do not need to select a Primary Care Physician, nor do you need to contact your PCP for referrals to specialists. However, because you are responsible for choosing specialists and hospitals, it is especially important to check with the plan by phone or their website to be sure the provider is in the network. The GIC's EPO is Tufts Health Plan Spirit.
POS (Point of Service): a health plan that provides coverage for treatment by a network of doctors, hospitals and other health care providers. Selection of a Primary Care Provider (PCP) is required. To get the lowest out-of-pocket cost, a member must get a referral to a specialist. The GIC’s POS plans are Harvard Pilgrim Independence Plan and Tufts Health Plan Navigator.
PPO (Preferred Provider Organization): With a PPO, you receive more comprehensive benefits by using network providers - doctors, hospitals and other health care providers - that participate in the plan. You have the option of using non-network providers, but with a lower level of benefits and higher out-of-pocket costs. Because PPOs usually have broader networks, they are generally more expensive - have higher premiums - than HMOs and EPOs. With a PPO, you do not need to select a Primary Care Physician. The GIC's PPO-type plans include UniCare State Indemnity Plan/Community Choice and UniCare State Indemnity Plan/PLUS.
Indemnity Plans: The GIC also offers Indemnity Plans - UniCare State Indemnity Plan/Basic for employees and non-Medicare enrollees and UniCare State Indemnity Plan/Medicare Extension (OME) and Harvard Pilgrim Medicare Enhance for Medicare members. These plans offer access to any licensed doctor or hospital. Make sure that your provider accepts Medicare. In large part because of the broad access, the UniCare Indemnity Plan/Basic is the most expensive GIC health plan option. Outside of Massachusetts, providers may "balance bill" you for charges above the plan's allowed amount. If you are a UniCare Basic member and use non-Massachusetts providers, be sure to contact UniCare so that they can provide you with their list of participating national providers that accept their payment in full.
The bottom line - be sure you know your health plan's type to maximize your benefits and reduce unexpected and costly out-of-pocket costs. With some plans, if you do not use participating providers for non-emergency care, you will have no coverage and in most instances will be responsible for a very expensive hospital and/or doctor bill.
This information provided by the Group Insurance Commission .