Healthcare Questions and Answers
Confused about Healthcare?
HMO, PPO, open enrollment, closed panel, copayment, fee-for-service; all these terms entered our vocabulary during the last decade. Sometimes the use of these words seems to make an already confusing situation even more confusing.
At Cedars-Sinai Medical Network, we take the role of educating our patients seriously, and education extends beyond telling you what pill to take and at what time, or what changes your body will go through during pregnancy. We strive to make your entire healthcare experience seamless - which includes helping you understand how the healthcare system works.
Managed Care or HMO
People using managed care to pay for their healthcare have signed up with an insurance company using a type of insurance that specifies how care is delivered. The term "managed care" means that the insurance company is taking responsibility for keeping the cost of providing care low while keeping the quality of care high.
Using the basic definition, an HMO plan means you must choose a primary care physician, and you must use the physicians who are contracted with that group and HMO for any care. If you do not, the HMO will not pay for the care.
Under managed care, you typically pay a small amount each time you see the physician, usually a $10 or $15 co-payment. These fees vary based on your insurance plan.
PPO Versus POS
PPO plan, the insurance company will give you a list of physicians you can see and still be covered, so you have more choice in selecting a physician. If you see a physician not included on that list, the insurance company may pay for some of the care but will usually require you to pay a larger amount.
POS plan , you have an HMO with a PPO option. When you need care, you choose to activate either the HMO or PPO option. The HMO and PPO options pay for different amounts - usually the HMO option covers more care, but you are more restricted to the physicians from which to choose.
Your insurance company will ask you to choose a primary care physician - usually a general internist or family practice physician - who will direct your care. At Cedars-Sinai Medical Group and Cedars-Sinai Health Associates, all of our primary care physicians are board-certified internists or pediatricians who diagnose and treat a variety of illnesses and injuries, and assess the types of specialized care you might need. In most cases, your primary care physician (often called your PCP) can care for most of your needs.
If you use an HMO or POS plan and need to see a specialist - such as an orthopedist, neurologist or cardiologist - your primary care physician will request a referral (or authorization) from the Utilization Management Department. This referral indicates to the insurance company that you have gone through the correct procedures for getting specialized care. At Cedars-Sinai Medical Group and Cedars-Sinai Health Associates, most of our referrals are automatic (or pre-approved), meaning they are given to you at the primary care physician's office and do not need further review.
In most cases, your referral will be automatic and you will have it with you when you leave your physician's office. This allows you to make an appointment with a specialist quickly.
While we cannot tell you to choose one plan over another, we can tell you it is important for you to consider various factors in making your choice, such as:
- How much you can afford to pay out of pocket
- Whether your current physician is part of one plan but not another
- How often you or your family need medical care
Individuals who prefer unlimited choices of physicians, who do not want the restrictions of managed care or who do not have healthcare coverage typically pay cash for their services. This is called fee-for-service. Sometimes an individual pays fee-for-service but has insurance and requests refunds from the insurer after seeing the physician. This is only possible with certain types of insurance. People paying fee-for-service can see any physician without a referral.
Medicare is a government-run program to pay for healthcare for individuals meeting certain criteria. Many people think that Medicare is for people over 65, but it also pays for healthcare of people with end-stage renal disease or certain disabilities. Medicare has two ways of paying for healthcare - HMOs (managed care) or fee-for-service (Parts A and B).
For more information on Medicare and how it works, visit the Medicare website sponsored by the Health Care Financing Administration) at www.hcfa.gov, or visit your local Social Security office.
How We Provide Medical Care
Cedars-Sinai Medical Network strives to make your healthcare experience as pleasant as possible - both clinically and administratively. We understand the frustrations of dealing with insurance companies when you or someone you love is in need of medical care. We also know that coming in for a routine physical should not be a hassle. We want to be part of your support network and provide the highest quality care that meets your needs.
For More Information
If you are new to the Cedars-Sinai Medical Network, we suggest you call our Patient Services Department. Our representatives will work with you to find a physician who meets your needs.