Employee Benefits Frequently Asked Questions
Q. What is an HMO?
A. An HMO is a Health Maintenance Organization and is typically the most affordable plan offered.
Health services are accessed through the Primary Care Physician chosen from the physician listed in the Provider Directory.
For each office visit, you usually pay only your copayment.
Q. What is a PPO?
A. A Preferred Provider Organization is a network of physicians that have agreed, by contract, to discount their rates to carriers.
These "preferred providers" may be Primary Care Physicians or Specialists, and PPO members are free to see any of them. PPO members may also access non-contracted providers, but usually at a higher out-of-pocket-cost.
Q. What is a POS?
A. Point of Service plan combines the cost savings of a HMO with the flexibility of a PPO. Most plans offer both Dual Option and Triple Option POS plans.
- Dual Option:
- Triple Option:
If you are looking for affordability, use the "In-Network" option of you plan. Just like an HMO, make an Appointment with the Primary Care Physician you have chosen from the Provider Directory. You will be charged only your copayment.
If you want flexibility, choose to go "Out-of-Network." Like a PPO, you can see any of the preferred providers."
This adds the option of seeing non-participating providers at a higher out-of-pocket-cost.
Q. What is the difference between Emergency Services and Urgent Care?
A. Emergency services is typically defined as those services required as a result of an unforeseen injury or acute illness for which a delay in treatment would result in a permanent physical impairment or loss of life.
Urgent Care, on the other hand, is defined as those services required as a result of unforeseen injuries and acute illness that require immediate attention.
A broken arm may be an example of an urgent care situation. If possible, insurance companies ask that you try to contact your primary care physician in an urgent care situation and arrange your care.
Q. What are "Medical Networks" and "IPA's"?
A. Most contracted physicians belong to either a Medical Group or and IPA.
A Medical Group is a partnership of Primary Care Physicians and Specialists. These physicians share the same medical offices and are employed by the Medical Group. An Independent Practice Association (IPA) is just that -a group of independent physicians that have joined together to work with health care companies. Physicians belonging to an IPA usually have their own offices, separate from other physicians in the IPA.
Q. An employee is laid off and he elects COBRA Health Continuation Coverage. After one year, the Employer rehires the Employee. Must this Employee satisfy any new waiting periods or be subject to pre-existing condition limitations, like any other new Employee?
A. No, this is because the Employee was continuously covered under the plan as a COBRA beneficiary during the period he was unemployed.
However, if the Employer offered medical and dental benefits and the Employee had elected only medical coverage under COBRA, then he will be required to satisfy the waiting period and be subject to the late applicant provisions and limitations that apply to dental coverage.
Q. If an employee terminates employment due to a work related disability, is he eligible to elect COBRA Health Continuation Coverage even though he is eligible to receive benefits under Workers' Compensation?
A. Yes, because the benefits will only be payable for the disabling condition under the Workers' Compensation coverage. Under COBRA, the Employee will be able to elect coverage for himself and his dependents and coverage will be for all conditions except Employee's disabling condition.
Q. What are some of the more common Acronyms and Abbreviations used in the health care industry today?
A. Acronyms and Abbreviations
- AB-Allowed Benefit
- AHA-American Hospital Association
- AMA-American Medical Association
- ASC-Administrative Service Contract
- C & S-Claims and Service
- CARE-Consolidated Adjudication and Reimbursement System
- COB-Coordination of Benefits
- COBRA-Consolidated Omnibus Budget Reconciliation Act of 1986
- COMP-Comprehensive Insurance
- CPT-Current Procedural Terminology
- DHMH-Department of Health and Mental Hygiene
- DHP-Delmarva Health Plan
- DMO-Dental Maintenance Organization
- ER-Emergency Room
- ECF-Extended Care Facility
- EOHB-Explanation of Healthcare Benefits
- EOMB-Explanation of Medicare Benefits
- FDA-Food and Drug Administration
- FEP/FEHP-Federal Employee Program/Federal Employee
- Health Plan
- HCACC-Health Care Access and Cost Commission
- HCFA-Health Care Financing Administration (Medicare)
- HIAA-Health Insurance Association of America
- HMO-Health Maintenance Organization
- HSCRC-Health Services Cost Review Commission
- ICM-Individual Case Management
- IHM-Integrated Health Management
- IMD-Individual Market Division
- IP-Inpatient
- JCAH-Joint Commission on the Accreditation of Hospitals
- LPN-Licensed Practical Nurse
- LPT-Licensed Physical Therapist
- MB-Medical Benefits
- MCO-Managed Care Organization
- MEOB-Medicare Explanation of Benefits
- MM-Major Medical
- NAIC-National Association n of Insurance Commissioners
- OCL-Outstanding Claims Liability
- OOP-Out- of- Pocket
- OP-Outpatient
- OPL-Other Party Liability
- PAR-Participating (plan, hospital, physician, etc.)
- PCP-Primary Care Physician
- PDR-Physician Desk Reference
- PPA-Preferred Provider Arrangement
- PPN-Preferred Provider Network
- PPO-Preferred Provider Organization
- PT-Physical Therapist
- QA-Quality Assurance
- RFP-Request for Proposal
- RPT-Registered Physical Therapist
- RX-Prescription Drug
- SRO-Self Referral Option
- SSA-Social Security Administration
- SSOP-Second Surgical Opinion
- TPA-Third Party Administrator
- UR-Utilization Review
For questions regarding Human Resources or employment regulations you may want to contact Jennifer McBennett of Seay Management Consultants at 407-426-9484 or email her.