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MAIA Insurance AgencyWhat is the major difference between an HMO, POS and PPO plan?HMO and POS plans both require the insured to select a primary care physician that, depending on the health plan, may or may not require referrals to be used. An HMO has no out-of-network benefit, and a POS plan has an out-of-network benefit at reduced benefits for the insured to utilize. A PPO plan is set up the same way as a POS plan, except the insured does not have to select a PCP and will not need referrals. Can I change my PCP at any time?Yes, you will be able to change a PCP at any time while insured. The process does require the insured to notify the insurance carrier in writing by usually completing a change form. What if the insurance carrier does not cover my prescription drug?If a prescription is not covered under the health plan formulary, the member is recommended to use a drug substitute that is on the formulary. If a member cannot take a substitute formulary drug for medical reasons, the doctor’s office must contact the insurance carrier to receive an approval for coverage of the nonformulary medication. The insurance carrier will then review the information and consider a possible exception. If the insurance carrier does not authorize coverage for the medication of the drug, the member will pay 100 percent out of pocket. If a woman has an OBGYN that is not her PCP and the PCP provides service for illness and physicals, how would this situation be treated with the health plan?The woman would elect the doctor who is for illness, injury and physical examinations as her PCP, and the OBGYN would be considered a specialist. If the member has an OBGYN who performs the physical examination also, she would still choose the doctor for illness and injury as her PCP. How are group insurance rates established?Group insurance rates are calculated by using the average age, location of the business and the nature of the business. Depending on the insurance carrier, there may also be medical underwriting used to determine the company’s final rate. What if I am traveling out of my service area and I have to utilize my insurance?Emergency care is usually covered regardless of where the insured is located, but for care that is not for emergency purposes, cost to the insured will be determined by the health plan carrier. |