Q. What is the difference between HMO and PPO coverage?

A. The level of benefits (i.e., generosity of coverage, deductible and copays), and the amount of freedom to choose among physicians and hospitals are usually the two main differences. See below . . .

HMO: A Health Maintenance Organization provides very rich benefits - often extensive preventive care coverage and low out-of-pocket costs. Unless you have a Point of Service option or except in an emergency, there is typically no coverage for care from doctors or hospitals outside your HMO. Plans usually offer comprehensive benefits and affordable premiums with no deductibles and minimal cost- sharing (such as low copayments for doctor visits and other services). A Primary Care Physician, that you select from within the network, oversees all your care. Unless you have a direct access feature in your plan - your Primary Care Physician will coordinate referrals to specialists when necessary.

PPO: A Preffered Provider Organization is a network of physicians and hospitals that have agreed, by contract, to discount their rates to members. The networks are typically very large, and the members are free to seek care from any physician or provider within the network, including specialists without a referral. Members may also access non-contracted providers, but at a higher out-of-pocket cost. Typically PPO plans might offer some front-end copayments for such services as doctor visits and prescriptions. Most other covered services (i.e., inpatient hospital services and surgeries) are typically subject to a calendar year deductible and/or coinsurance (where applicable).

Q. Who is eligible to join an Individual Plan?

A. Any individual, student or family who is not eligible for Medicare may apply. With most plans, children can even be signed up independently (parents don't have to enroll). See specific plan for details.

Q. What about pre-existing conditions?

A. Pre-existing condition limitations vary from plan to plan and from state to state. Please refer to the plan brochures for specific details regarding pre-existing conditions.

Q. Is maternity coverage available?

A. Again this will vary from plan to plan. In many plans, maternity coverage might be an option, and in others it may be included. Generally, HMO individual plans will typically offer better and more affordable maternity coverage than PPO individual plans. See plan brochure for details.

Q. What is a Primary Care Physician?

A. A Primary Care Physician is trained to manage you entire health care program. Primary Care Physicians typically include Family/General Practitioners, Internists, and Pediatricians. If you choose an HMO plan, you will usually be required to select a PCP from the available network. With a PPO plan, you usually are not required to select a PCP, and you are available to visit any physician within the network, however it is still a good idea to establish a relationship with a regular physician. Online Provider Directories are available from this site to assist you in searching for physicians and/or hospitals.

Q. Do I have to complete any claim forms?

A. With a managed care plan (HMO or PPO), there are virtually no claim forms to complete. When you visit your physicians office or other health care provider in-network, you will typically show them your Plan Identification Card and they will handle the rest.

Q. How long does the application process take?

A. This will vary slightly depending on the plan you select, however on average you usually will hear back within two to three weeks. The process could take longer sometimes, if additional information and/or medical records are requested.

Q. When will my coverage take effect?

A. Unlike some other types of insurance, health insurance cannot be bound for coverage immediately. Your application for coverage will go through an underwriting process and does need to be approved by the insurance company you are applying with. With some plans, coverage can only be started on the 1st of the month - with others you may be able to specify a requested effective date on or after the date you sign your application. See specific plan for details.

Q. What if I only need coverage for a few months?

A. Health insurance does not typically have a specific term associated with it. As long as you continue to pay your premium, you policy will continue. If you need temporary insurance for a short period of time you may want to consider Short-Term Coverage. This type of coverage is generally easier to apply for, quicker to process, and also less expensive than permanent coverage. This is a non-renewable policy and is applied for with one premium payment for the term you select.