Which plan is right for me? |
Feature |
HMO |
PPO |
|
You must select a PCP. Services are available from specific doctors for a specific copayment: no claims to file: no coverage out-of-network (except for emergencies.) |
Services are available from a large network of doctors: services are subject to deductible, copayment and coinsurance; you may have to file a claim; out-of network coverage is available at a lower benefit rate. |
Network |
7,055 PCPs and 28,793 specialists for a total of 35,848 HMO doctors in Texas. |
10,837 PCPs and 38,959 specialists in 254 counties in Texas, and 720,000 participating physicians across the U.S. |
Service area |
220 counties in Texas. |
All 50 states, plus Puerto Rico. |
Network services |
Except for emergency care approved referrals, only services provided in the network are covered. |
Services performed in-network and out-of-network are covered at different levels. |
Primary Care Physician |
Your PCP coordinates all medical care. |
Freedom to chose any doctor, hospital, or specialist. |
Referrals |
PCP must refer you to specialists and hospitals. |
Referrals are not required. |
Deductible |
No deductible or coinsurance. |
$200/$600 in-network.
$400/$1,200 out-of-network. |
PCP visit |
Most common copayment is $20. |
Most common copayment is $30 in-network |
Specialist visit |
Most common copayment is $45. |
Most common copayment is $50 in-network. |
Coinsurance |
Most services covered at 100% after copayment. |
Services covered 80% (or 60% out-of-network) after annual deductible. |
Billing |
No balance billing.
No claims to file. |
No balance billing, unless you seek out-of-network services; you must file a claim to seek reimbursement. |
Preventive Care |
Routine preventive care such as well-baby, well-woman and well-man exams are free: annual physicals are covered with $0 copayment. |
Preventive care such as well-woman and well-man exams are free in-network and annual physicals are covered with $0 copayment. Limitations for out-of-network. |
