eLearning Tool – Understanding Your HMO/PPO Benefits – Eng 1

Hello and welcome to the enrollment education video here will go over important terminology along with how to read and understand your health insurance summary of benefits documents this information will help you choose which plan best fits the needs of you and your family let's get started two terms you will need to know right away.

Our HMO and PPO HMO stands for health maintenance organization and PPO stands for preferred provider organization the biggest difference between the two is that having an HMO means that unless it's an emergency you must receive care at an in-network HMO provider with a Florida blue HMO plan also known as blue care you will.

Need to choose a primary care physician or PCP but you will not need a referral to see an in-network specialist a PPO plan does not require you to choose a primary care physician and you are free to see whomever you choose in-network or out-of-network some of our PPO plans are also known as blue options or blue choice so the big differences with an.

HMO you may only use in-network providers let's define some other terms a deductible is the amount of money you will need to pay before your health plan begins paying a copay is a set dollar amount that you pay for covered services it is a fixed price and may differ between types of providers coinsurance is the sharing of costs between you and.

Your health plan after your deductible is met such as 80/20 where Florida blue pays 80% and you would pay 20% lastly the out-of-pocket maximum is the maximum amount you can pay out-of-pocket during a benefit year deductibles co-pays and coinsurance count towards your out-of-pocket maximum there are some other common terms a.

Provider is a person or institution that provides services an in-network provider is someone who participates within a health plan network like blue care or blue options and whose members pay less because these providers have negotiated discounted rates with Florida blue an out-of-network provider is not in your network and therefore out-of-pocket.

Costs will be higher the last few terms we need to cover are covered services allowed amount and balance billing a covered service is a medical service that is an eligible expense under your health plan the allowed amount is the maximum amount an in-network provider is allowed to charge for that service balanced billing is an additional amount.

Members may be billed by the provider if they seek care from an out-of-network provider this is why we always recommend using in-network providers so you will never pay more than the negotiated discounted rates okay now that we've covered the important terms let's move on to the summary of benefits you have received one or more of these that your.

Company has chosen for your health insurance plan selection these summaries are where you will find all of the details of covered services including your deductible and out-of-pocket maximum keep in mind that there is a name at the top of the page blue options blue care etc and this refers the name of the network associated with this plan.

Let's start here with office services this section tells you what your costs will be for services like family physician or specialists office visits remember a copay would mean there is a flat dollar payment for that visit while deductible and coinsurance would mean you'd be required to pay the Florida blue rate for that covered visit until.

You have met your deductible up to your out-of-pocket maximum limit this next section preventive care is particularly important for staying healthy here you will find a few preventive services that are offered to you at low or no cost these may include immunizations routine checkups including have work well-child checkups mammograms and cancer.

Screenings be sure to take advantage of these services the emergency medical care in the event of a medical emergency you need help fast this section gives you the cost for using an emergency room in urgent care center convenient care clinic and ambulance services in a life-threatening emergency you may want to use an ER but for non.

Life-threatening situations you will save money by using an urgent care center or convenient care clinic outpatient diagnostic services in this area you will find your cost for services like x-rays MRIs and blood work at outpatient diagnostic locations remember to always use your in network labs in order to avoid out-of-network.

Charges in the state of Florida quest Diagnostics is the in-network provider but you should verify the lab of choice if you're outside of the state Florida blue comm is a convenient way to verify and network providers not only in Florida but anywhere else in the country or the world the other provider services section.

Shows you the cost associated with using a radiologist a pathologist or anesthesiologists other special services is where we show you the cost for services such as cardiac rehab speech therapy physical therapy durable medical equipment home health care and other skilled nursing services the hospital Surgical section shows how.

Florida blue covers in or outpatient procedures including surgery at an ambulatory surgical center inpatient hospitalization prehabilitation or emergency room facility services the financial features section is particularly important as it lists your annual deductible coinsurance and out-of-pocket maximum the first number.

Would be per person while the second number would be a family aggregate and remember the coinsurance is the percentage you would pay for services after the deductible is met and the out-of-pocket maximum is the maximum you would spin in a benefit period including deductible coinsurance and co-payments your plan may also include prescription.

Drug coverage and your cost depend on what pharmacy you choose and whether you use a generic or name-brand medication to determine your cost you may look your medication up online at Florida blue comm or simply review the prescription medication guide we have included in your digital kit prescription medications are categorized in tiers one.

Two and three tier one is generic prescription tier two is a preferred brand and Tier three is a non preferred brand medication generics Tier one are usually the lowest cost while non preferred brands are typically the most expensive using an in-network pharmacy will help reduce these costs many pharmacies offer promotions on a wide.

Number of generics so make sure you speak with your pharmacist about their programs you may also choose to use our convenient mail-order where he can get a 90 day supply for much lower than the cost of getting it locally remember the best way to save money is to utilize an in-network provider and pharmacy our online tool is available 24/7 and makes.

It easy for you to search your network this concludes the enrollment education video we hope it makes you more knowledgeable when reviewing your summary of benefits

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