Highmark community blue flex ppo providers

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This also means when you are traveling, you can receive care wherever you are. Additionally, PPO plans offer more options for laboratory service providers. When you need lab work done, you can choose the most convenient location under a PPO network. If you need a lower monthly fee, consider an HMO plan.

If you travel frequently and are more likely to need care while away from home, especially if you are living with a chronic condition, or enjoy high-risk hobbies such as certain sports, you may need a PPO to provide the best coverage for your needs. If you need a lot of specialist care, say you are managing a rare or chronic condition, you may also prefer the ease of choosing specialists and seeing them right away that you get with a HMO plan.

If you mostly get care in your home city or mostly from your family physician, an HMO is more likely to provide the right coverage for you.

If you would like to keep your doctor, you can determine whether he or she is in-network under an HMO plan, a PPO plan or both. Choosing the right health plan can give you peace of mind, knowing that your insurance plan has your health needs covered. Get a Quote. Skip Navigation. Login Register. Have questions about health insurance?

Explore our Insurance Basics pages. Need Insurance? Log In or Register. Things to consider when choosing between HMO and PPO: To choose the right plan for you and your family, you may want to consider the following: Do you need a lower monthly payment?

A member may be responsible for multiple copayments per visit and also to pay at the time of service. A copayment may not apply toward deductibles or coinsurance, and may not accumulate toward the out-of-pocket limit. Deductibles, coinsurance, and copayments are examples of member cost sharing.

Covered Service Benefit A service or supply for which health care coverage will be provided by the health plan. D Deductible A specified dollar amount a member must pay out of their own pocket before the health plan begins to pay for any covered services some services may be exempt from the deductible. The member may be required to pay any applicable deductible at the time of service.

E Exclusive Provider Organization EPO A health care plan which provides benefits when care is received from network providers, and for emergency care when received at either network or out-of-network providers.

Explanation of Benefits EOB Statement sent by a health plan that details the charges for the service s received, the plan's allowable charge s for the covered service s , the amount the health plan pays for the service s , and the amount s the member is responsible for paying. F Fee-for-Service A payment system where the care provider is paid for each service rendered rather than a pre-negotiated amount for each patient. Fee Schedule A complete listing of fees used by health plans to pay doctors or other providers.

Flexible Spending Account FSA A health savings account that allows people to contribute a specified amount from their paycheck to help pay for health care services. Contributions are tax-exempt. Formulary A listing of prescription drugs selected by the health plan based on clinical analysis, unique value, and safety. This listing is subject to periodic review and modification by the health plan or a designated committee of physicians and pharmacists.

G Group Health Plan A health plan offered by an employer that provides health coverage to employees and their dependents.

Guaranteed Issue Under guaranteed issue, a health insurer must provide coverage to an applicant regardless of prior medical history. HIPAA helps plan members continue their health coverage and establishes equality between individual and group health coverage. Health Maintenance Organization HMO Health care coverage that requires all members to select a primary care provider PCP who is responsible for supervising, coordinating and providing basic medical services.

All non-emergency covered services must be obtained from network providers unless pre-authorized by the health plan. Funds remaining in the account at year-end go back to the employer. Account contributions are not taxed. Treasury Department.

These guidelines require 1. A member must be enrolled in a qualified HDHP to establish and contribute to a health savings account.

I Indemnity Traditional fee-for-service health coverage in which covered health care services received from participating providers are paid-in-full after any applied deductibles, copayments or coinsurance costs have been met. M Maintenance Drugs A prescription drug prescribed for the control of a chronic disease or illness, or to alleviate the pain and discomfort associated with a chronic disease or illness.

Managed Care Health care coverage offered by health plans where there is an organized way for contracting with providers, and processes in place to manage costs, use of services and the quality of the delivery of health care. Maximum The greatest amount of benefits that the health plan will provide for covered services within a prescribed period of time. This could be expressed in dollars, number of days or number of services.

Medically Underwritten Plans that base acceptance for enrollment on health status, determined by the answers given on a medical questionnaire. N Network Group of physicians, hospitals and other health care providers and suppliers contracted with the health plan to offer health care services at negotiated rates. O Open Enrollment A period each year when a member has the opportunity to change or elect their health care coverage.

Out-Of-Network Provider Physicians, hospitals or other health care providers who do not contract with a health plan. Out-of-Pocket Maximum The maximum dollar amount a member is required to contribute towards the cost of covered services in a benefit period. This limit protects a member from very high costs by capping the total amount they will have to pay for covered health care services. The out-of-pocket limit always includes coinsurance, and may include other cost-sharing amounts such as copayments or deductibles.

Some services may be excluded from the out-of-pocket limit such as prescription drug expenses. P Participating Provider A health care provider who has been contracted to give medical services or supplies to health plan members for a pre-negotiated fee on indemnity health care plans.

Pre-Authorization The process in which a member or provider must contact the health plan prior to a non-emergency hospitalization or other selected services, in order to receive authorization for these services. Pre-existing Condition A condition for which medical advice, care, treatment or diagnosis has been recommended or received from a provider within a designated time period immediately preceding the effective date of coverage.

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