With HMOs, out-of-network care is typically not covered. You must see this doctor first and get a referral to specialists or other providers. Health maintenance organizations (HMOs) require insured members to choose a primary care physician who will coordinate their care.HMOs and PPOs tend to work off this copay model: No matter what network design or plan type you choose, be sure to see how out-of-network care is covered. If you seek care out-of-network in either of the examples above, your plan will pay 50 percent coinsurance while you pay the other half of the covered out-of-network expenses.That means you will be billed for 25 percent of the covered expenses and your plan will pay up the remaining 75 percent. However, if you visit the emergency room, your plan requires you to pay 25 percent coinsurance.Your plan requires you to make a $25 copay at the doctor’s office. You need to see your primary care physician.Here is an example of how traditional copay plans work: Some services may require coinsurance instead. A copay is a set amount outlined in your plan benefits. Then, when you need medical care, you are responsible only to make a copayment or copay. As with all health insurance coverage, you will pay your monthly premium for access to benefits. Major medical insurance is designed with set copayment amounts for specific healthcare benefits. Some plans are even a combination of the two.Īs you navigate the metal tiers of major medical insurance plans and dig into high-deductible health plans, you will want to be aware of how these plans function so you can select the best coverage. Your health insurance may be oriented around a traditional major medical structure (with copayments) or a health savings account (HSA)-compatible high-deductible health plan (HDHP).
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