What is an HRA?
The HRA is a type of Consumer Driven Healthcare Plan. In the HRA, you may receive care from either in-network or out-of-network providers. The HRA does not require you to select or have your care coordinated through a primary care physician. You do not need a referral to see a specialist. The HRA has a higher deductible than the other Medical Plan options. However, the plan also provides you with a company-funded account you can use to help satisfy the deductible. You pay nothing out of your pocket until you’ve used all the money in your HRA. Then, you pay the full cost of covered services until the deductible is met. After you meet the annual deductible, you will pay either 20% for in network care or 40% for out-of-network care. If your expenses for out-of-network care are more than R&C charges, you will be responsible for the amount that is in excess. Once you have satisfied the plan’s annual in-network out-of-pocket maximum, your allowable expenses will be paid at 100% for the remainder of the year.
Two special notes about the HRA:
1. Prescription purchases apply to the HRA deductible. When you buy a prescription drug through the HRA plan, your cost is applied to the deductible. Your prescription costs help satisfy the deductible, an advantage that is unique to the HRA.
2. The HRA and the Health Care FSA are different. The company-funded account in the HRA is not the same as the Health Care FSA.
What is an HMO?
Health maintenance organizations (HMOs) have been on the health care horizon for more than 50 years, but it's only in the last decade that they have become a major presence on the American health plan landscape. In 1980, HMOs served fewer than 10 million people compared to membership rosters topping 77 million in recent years.
The popularity of HMOs has grown as health care costs have escalated, and they can save money for both you and your company. But as with any membership, you'll want to know how to maximize participation in your plan. HMO medical plans cover a wide range of health care services, and the more you know about your HMO plan and how it works, the better health care consumer you'll be.
Your HMO plan is designed to have the primary care physician (PCP) you choose coordinate your care. Your PCP is a member of your HMO's network of physicians and hospitals. HMO providers have agreed to offer services at special rates to plan members. When you use your PCP or get a referral from your PCP, you may not have to pay an annual deductible, and you generally pay a modest copay.
Seeking care through your PCP can be convenient. Your insurance membership card is your ticket to care; no claim forms are necessary.
Be careful. Most HMO plans are designed so you must coordinate all your care through your PCP. If you don't, the care will not be covered except in an emergency, as defined by your HMO.
CHOOSING A PCP
When you enroll for your HMO plan, you'll want to choose primary care physicians (PCPs) for each covered member of your family. These are the HMO doctors who will coordinate your care. The PCP you choose is likely to be the one you will visit most often, so choose carefully.
If you have a family, you may select one general practitioner as the PCP for your entire family, or you may select different doctors for different family members. With some plans, you can choose a pediatrician for your children and another doctor for yourself. Some plans encourage women to name a PCP for their general care and an ob/gyn for services such as pelvic exams and pap smears.
Review the list of PCPs offered by your plan. Your health care company may have a web site with an up-to-date directory of HMO providers, or you may request a printed directory or call your health care company. You may want to narrow the list to those who practice within a reasonable distance of your home or work. Check with friends, family and neighbors to hear how satisfied they are with their doctors. Ask questions about waiting time for appointments and responsiveness to emergencies.
Next, you'll want to check the doctor's credentials. Your health care company can tell you the requirements that its HMO providers must meet
What is a PPO?
Preferred provider organizations (PPOs) combine some of the cost-saving advantages of managed care with more choice for health care consumers.
Like HMOs, PPOs include networks of physicians and hospitals that have agreed to discount their rates for plan members. But, unlike HMOs, many PPOs do not use primary care physicians (PCPs) to oversee a patient's overall care, so you can consult a specialist whenever you feel it necessary. When you consult physicians outside your PPO network, however, you will receive less reimbursement and you may be subject to an annual deductible.
In addition to having a lower copay to see network providers, seeking care within your plan's network may also be more convenient. Your insurance membership card is your ticket to care; no claim forms are necessary. However, it's your choice each time you need care. As with any medical insurance plan, the more you know about your PPO plan and how it works, the better health care consumer you'll be.
Pre-Authorization and Emergencies:
Familiarize yourself with any services that require pre-authorization such as childbirth, elective surgeries or a hospital stay and ensure you've followed the appropriate steps before you have any of these services performed. In an emergency (as defined by your plan), or if you are traveling outside the area and you can't use HMO providers, be sure to follow the plan rules. Generally, in an emergency, you are covered if you notify your HMO within a certain period of time, even if you don't coordinate care through your PCP
When to go to the ER:
"Emergency" - the sudden onset of a medical or behavioral condition that causes sufficiently severe symptoms or pain. In the absence of immediate medical attention, the emergency could be expected to result in:
> placing the health of the person in serious jeopardy (or placing others in jeopardy in the case of a behavioral condition)
> serious dysfunction of any organ or body part
> serious disfigurement
> serious impairment to bodily functions