Medical Insurance FAQs

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Here are some FAQs on Group Health Insurance:

What is an HMO?
A Health Maintenance Organization (HMO) is a benefit plan that has only one benefit level: in-network; it allows enrolled members to use participating HMO doctors in order to receive benefits. HMO members must have all of their care authorized by their Primary Care Physician (PCP). There are minimal copayments for doctors visits such as $10, $15 or $20. There are no out-of-network benefits.

What is a POS?
A Point-of-Service (POS) is a benefit plan that has two benefit levels: in-network and out-of-network. In-network benefits provide the same cost and quality controls of the HMO product with minimal co-payments. Employees are required to select a PCP from the insurer's directory of participating doctors. The member's PCP will coordinate all of the members' health care needs. Members can choose, at the time services are needed, to seek care from an in-network provider or go out-of-network and receive benefits that are subject to deductibles and coinsurance.

What is an EPO or Direct HMO or Open Access HMO?
These benefit plans have one benefit level: in-network. In-network benefits usually require co-payments. Referrals are not required to access in-network benefits. Members must select in-network providers to seek care for needed services. There are no out-of-network benefits.

What is a PPO?
A Preferred Provider Organization (PPO) is a benefit plan that has two benefit levels: in-network and out-of-network. In-network benefits provide benefits to members with minimal copayments. Referrals are not required to access in-network benefits. To maximize in-network benefits, members must select in-network providers to seek care for needed services. Members can choose to seek care from an out-of-network provider and receive benefits that are subject to deductibles and co-insurance.

What is a Co-Pay?
The amount of money the insured must pay to the in network doctor. Usually $10, $15 or $20 per visit

What is a Deductible?
The initial amount the insured pays before any reimbursement is made by the insurance carrier. This term usually applies to out of network benefits only. It sometimes may apply to prescription drug coverage as well.

What is Co-Insurance?
The amount the insured must pay in addition to what the insurance company pays. It is the sharing of the medical care bill. Example: When an insured goes to an out of network doctor, after the deductible has been applied, if the insurance coverage has a 70/30 coinsurance, the insurance company pays 70% of the bill and the insured pays the remaining 30%.

How much must the employer contribute toward the purchase of health insurance?
An employer contribution program allows you to fix your company's insurance costs. You can select a fixed dollar amount, a percentage of premium or whatever financial formula is best for your company. When you decide what the employer contribution will be, you should inform your employees of that amount.

What is the difference between 2, 3 and 4 tier rates and which one should I choose?
Two tier rates are single and family combinations and anyone enrolling other than single will pay the family rate. Three and four tier rates have a combination of Single, Employee with Spouse, Employee with Child(ren) and Family. Rates for 4 tier are based on the status of the employee at the time of enrollment and offer lower rates for the middle tiers while being higher for the family. Which one you choose depends on the breakdown of your employees, based on their status (single, married, single parent, etc.)

What if I have other questions?
You can always call us at 718-932-3300 or post them below.

Have another group insurance question for us? Use the form below, and we'll post the answer right here on this page.

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