1. Preferred Provider Organization (PPO)
More flexibility to use providers both in-network and out-of-network. You can usually visit specialists without a referral, including out-of-network specialists.
a. Examples: BlueShield, BlueCross, Aetna Choice Plus/open access, United healthcare, Cigna.
b. Please see #10 for your responsibility if you have a deductible, percentage copay, etc.
2. Health Maintenance Organization (HMO)
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO group. HMOs have lower monthly premiums, lower out-of-pocket costs, and sometimes there is no deductible (a set dollar amount you must pay out-of-pocket before your insurance starts paying doctors’ bills). HMO plans can be with BlueShield, United Healthcare, Aetna, Alameda Alliance, and many others. When you choose an HMO plan, you will need to pick an HMO group, AND a primary care provider, or the insurance will assign a doctor for you. Every HMO Group has their own separate rules on what is required to see a specialist provider. There also might be limits to staying in a certain county, based on your HMO group. YOU MUST CONTACT THE GROUP TO ASK ABOUT REFERRALS, HOW TO SEE A SPECIALIST, ETC.
Examples of HMO Group requirements-
- Hill Phyician Medical Group: Annual written referral from primary care provider is required for office visits and continued care. Surgery and treatments require the specialty office to submit authorization request to Hill Physician directly for approval prior treatment. A separate visit is required for treatments so authorization can be requested. YOU CAN ONLY BE SEEN IN ALAMEDA COUNTY.
- Physicians Medical Group of San Jose (PMG): requires primary care provider to submit request directly to PMG for authorization to have consult with a specialist. For all future follow ups and/or treatments, the specialty office will directly request from PMG to get authorization. Separate visit required for treatments so authorization can be requested. YOU CAN ONLY BE SEEN IN SANTA CLARA COUNTY IF MEDI-CAL BASED.
- Alameda Alliance: Annual written referral from primary care provider. Surgery and treatments require the specialty office to submit authorization request to Alameda Alliance directly for approval prior to treatment. Separate visit required for treatments so authorization can be requested.
YOU CAN ONLY BE SEEN IN ALAMEDA COUNTY.
- Valley Health Plan: requires primary care provider to submit request directly to VHP for authorization to have consult with a specialist. For all future follow ups and/or treatments, the specialty office will directly request from VHP to get authorization. Separate visit required for treatments so authorization can be requested. YOU CAN ONLY BE SEEN IN SANTA CLARA COUNTY.
3. Exclusive Provider Organization (EPO)
A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency). Sometimes a referral or authorization is needed to see a specialist.
4. Point of Service (POS)
You have the option of using a PPO plan or HMO plan. You pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s HMO network. Referral or authorizations is required when using the HMO option. Our office ONLY accepts the HMO side.
5. High Deductible Health Plan PPO (HDHP)
An annual deductible must be met before plan benefits are paid for services. This means that any office visit or services done at your specialist are your responsibility until the deductible is met. Once the deductible is met, your insurance will pay for a percentage of the services.
6. Health Savings Account (HSA):
Is a tax-advantaged savings account that you can use to pay qualified medical expenses that your HDHP doesn’t cover. Usually given a credit card to use at office to pay for your deductible. Please see section 10.
7. Health Reimbursement Arrangement (HRA)
Is a tax-advantaged savings account that you can use to pay qualified medical expenses that your HDHP doesn’t cover. With a HRA you do not pay at the time of appointment. The office submits the claim and your insurance will take the money out of your HRA and send directly to your doctors office. Please see section 10.
8. Medicare advantage Plans:
When you get Medicare insurance, you have the option of choosing a medical advantage plan over regular Medicare. Once you choose the plan, your regular Medicare is inactive. There are many Medicare advantage plans. You can choose HMO plans and PPO plans. The plan you choose will be subject to those insurance rules.
- Alignment, vitality, Brand New day, and Central Health and examples of special Medicare advantage plans that we only take as an HMO plan.
- There also are United Healthcare, BlueCross, Aetna, and BlueShield Medicare advantage plans that can be HMO/PPO.
9. Cosmetic Procedures
Filler, Botox, skin tag removal, benign mole removal are all examples of cosmetic procedures that insurance will NOT cover. Patient’s a responsible to pay for these procedures. We will not submit a request for approval through insurance.
10. Patient Responsibility
We can only tell you prior to the visit, an estimate of what your visit responsibility will be- due to the variable nature of all visits, and the different contracts that we have with the multiple insurance plans that we contract with. Initial visits, without a procedure, are generally billed with codes 99203 or 99204, and follow-up visits with codes 99213 or 99214. You can call your insurance/go to the insurance website, before we see you to get your exact responsibility for these codes. Procedure codes can also be given to you, AFTER/DURING your initial visit. We also can assist you by looking up the codes/your responsibility, in many, but NOT all cases. Ultimately your insurance website/customer service is the most accurate.
In general, procedures are not done during the initial or follow-up visits, and must be scheduled separately, as a procedure visit, due to insurance company requirements, or the need for insurance company/medical group authorization, or time/equipment/ personnel requirements.