This blanket term is used to describe the primary system through which health care services are provided in the U.S. An insurance company directs—i.e. manages—the way you get your treatment, from regular check-ups to accidents to major illnesses. Managed Care Organizations (MCOs) include the doctors, hospitals, laboratories, and clinics that make up your network.
HMO (Health Maintenance Organization):
HMO plans set up a network of doctors and other health care providers for your health care needs. HMO plans require you to choose a Primary Care Physician (PCP) who functions as a gatekeeper for your care. Under HMO plans, you need a referral from your PCP to see a specialist or receive any type of treatment or care (except for emergencies) your PCP does not provide. If you’re unsure exactly what kind of policy you have but you know you need a referral to see a specialist, then you most likely part of an HMO. Compared to other types of plans, HMOs generally have lower premiums and co-pays, but their networks tend to be smaller.
PPO (Preferred Provider Organization):
Like HMOs, PPOs set up a network of doctors and health care providers for your health care needs. Under a PPO plan you typically don’t need to choose a gatekeeper Primary Care Physician (PCP), which means you don’t need a referral to see a specialist. PPO networks tend to be larger than HMO networks, but the premiums, co-pays, and deductibles tend to be higher.
POS (Point of Service):
Like HMOs and PPOs, POS plans set up a network of doctors and health care providers for your health care needs. Under a POS plan, you pay much less if you use doctors in your network. POS plans often require you to choose a Primary Care Physician (PCP) and get referrals to see any type of specialist.
EPO (Exclusive Provider Organization):
Like HMOs, PPOs, and POS plans, EPOs set up a network of doctors and health care providers for your health care needs. However, under an EPO plan, your costs will be covered only if you use providers in the network.
Health insurance companies create contracts with groups of doctors, hospitals, laboratories, and other health care providers to form a network. The idea of a network is that the insurance companies pre-negotiate specific rates for health care services with a group of providers, then encourage you to use them. Therefore, an In-Network provider is any provider in the group your insurance company has a contract with.
An Out-of-Network provider is any doctor or health care provider who does not have a pre-existing contract with your insurance company.
You see or hear In-Network/Out-of-Network before lots of different insurance terms such as deductible, benefit, co-pay, maximum, etc. In these contexts, the phrases almost always refer to your level of coverage or how much you have to pay for services you receive from providers who are either in or out of the group your insurance company has pre-negotiated contracts with.
A Single-Case Agreement is when a provider such as Evolve works out a special contract so that out-of-network providers can work with your insurance company on an in-network basis. We have extensive experience working with insurance companies to create Single-Case Agreements for teens with emotional, behavioral, or substance abuse disorders.
This is the amount of money you must pay per year for medical expenses before your coverages kicks in and starts covering your expenses. For instance, if you have a $500 Annual Deductible, you’re responsible for the first $500 of expenses. After $500, your insurance plan pays whatever percentage of costs your plan specifies. Monthly premiums, copays, and prescription drug costs do not count toward your deductible.
Before the Affordable Care Act (ACA), many plans placed a limit they’d pay each year for any given illness or injury. For instance, if your plan had a $30,000 annual maximum for substance abuse treatments, then your insurance would pay all expenses up to $30,000, after your annual deductible. Annual Maximums are now illegal under law. With the current state of flux regarding the ACA, it’s unclear whether Annual Maximums will be reinstated or not. We will update this information as soon as it’s available.
Before the Affordable Care Act, many plans placed an overall limit they’d pay for any given illness or injury—just like the annual maximum, but calculated over your lifetime. Lifetime Maximums are now illegal under law. With the current state of flux regarding the ACA, it’s unclear whether Lifetime Maximums will be reinstated or not. We will update this information as soon as it’s available.