Not really sure what an HMO really is? Do you only “Kinda, sorta” understand deductibles? Health insurance seems to have a language of its own and you want to be sure you’re choosing the right plan. Here, we’ll try to help you by explaining some of the most common terms you’ll see while you’re shopping for insurance.
A fixed price you pay when you get certain health care services. Not all services require a co-pay.
HMO stands for Health Maintenance Organization. If you choose a plan that is an HMO, you must use in-network providers in order to get your services covered. If you go to an out-of-network provider, the plan won’t cover the cost of your care, except in an emergency. If you enroll in an HMO, you will also need to choose a primary care provider (PCP). You may need to get a referral from your PCP if you need care from specialists. Most of the plans offered through the Health Connector are HMOs.
Plan Type (ConnectorCare)
There are different ConnectorCare Plan Types that you may qualify for, based on your household size and income. All of the plans in each Plan Type have the same costs for covered benefits.
PPO stands for Preferred Provider Organization. You will pay less if you use providers that belong to the plan’s network. If you go to providers outside of a PPO’s network, the plan will only cover part of the cost of your services. You may be able to see specialists without a referral from a primary care physician (PCP) if you are enrolled in a PPO.
The amount you pay each month for your health insurance. You must pay your premium every month, whether or not you use health care services. The Health Connector will send you a bill for your premium each month. The premium will always be due by the 23rd of the month.
Primary Care Physician (PCP)
The primary (main) doctor that you go to for care are and services. If you need a specialist, your PCP will coordinate that care and give you a referral. If you enroll in an HMO or EPO, you will need to choose a PCP.
We offer standardized plans within each metallic tier (level). Standardized plans have a set of 21 major benefits in 2017 with the same out-of-pocket costs, to make it easier for members to compare the plans. Non-standardized plans can have varying out-of-pocket costs for all benefits and are also offered within each metallic tier. If you see the word “Standard” in a plan name, it means that the benefits are standardized and the plan may be easier to compare with other standardized plans in the same metallic tier.
Within each metallic tier, the cost sharing (out-of-pocket costs) for standardized benefits are the same.
- Plan names. Names of standardized plans vary by the insurer (insurance company) that offers the plan.
- Provider networks. The health care providers (such as doctors and hospitals) may be different in each plan’s network. Go to our Find a Provider tool to see which plans have the providers you want.
- Costs for other services. Be sure to check each plan’s Summary of Benefits and Coverage (SBC) for more details.