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Health Insurance FAQs

HMO Health Insurance Policy Features - South Carolina

  Preventive care emphasis Primary care physician (PCP) coordinates your total care Must get a referral from your PCP to visit a specialist Fixed monthly fee

HMO Health Insurance Policy Overview - South Carolina

Subscribers to an HMO receive medical services from participating physicians, clinics and hospitals. You choose a primary care physician (PCP) from a list of participating doctors from where you live in South Carolina. That doctor is used for typical circumstances such as annual exams and usual health issues. If you need to see a specialist, be hospitalized, or have lab or X-ray work, your doctor will refer you to a provider or facility within the HMO system. Your doctor must give authorization for those services to be covered by your HMO. In other words, you must see HMO approved physicians and use HMO approved facilities or pay the entire cost of the visit yourself. Similar to Point-of Service (POS) and PPO's, HMO's have made arrangements for lower fees with a network of health care providers and give their policyholders a financial incentive to stay within that network. You may have to pay some portion of the cost (co-payment) for each office or hospital visit, such as $20 - $30 per doctor visit, regardless of what the services cost. Also, some services such as emergency room, mental health and chemical dependency services, may carry additional costs in a South Carolina HMO health maintenance plan. PPO Health Insurance Policy Features - South Carolina Convenient access to quality health care Large and diverse network available of primary care physicians, specialists, hospitals & clinics. Pay for services as they are provided  

PPO Health Insurance Policy Overview - South Carolina

  You can see any health care professional in the network any time you choose to make an appointment. You don't need referrals for specialists or other services as you do in an HMO. You can see doctors or specialists outside your PPO network, however, your portion of the costs will be higher. You may have to pay some portion of the cost (co-payment) for each office or hospital visit, such as $20 - $30 per doctor visit, regardless of what the services cost. Also, some services such as emergency room, mental health and chemical dependency services, may carry additional costs in a South Carolina PPO health insurance plan.

 POS Health Insurance Policy Features - South Carolina

Preventive care emphasis Pays benefits for out-of-network care, but at a lower level  

POS Health Insurance Policy Overview - South Carolina

  Less restrictive than an HMO or PPO, a (POS) or Point of Service plan lets you see any licensed health care professional for anything covered by the insurance. Care you receive from out-of-plan health care professionals is reimbursed, but you must pay an often times much higher co-payment or deductible amount. While you may choose to see a physician outside the network, if you don't receive permission from your (PCP) primary care physician, you're likely to end up submitting the bills yourself and receiving only a small reimbursement...if any. Costs that exceed your deductible are covered by a co-insurance plan in which you and the insurance company share the cost for services covered by the policy. Also, some services such as emergency room, mental health and chemical dependency services, may carry additional costs in a South Carolina POS health insurance plan.

Fee-for-Service or Major Medical Health Insurance Policy

(Family or Individual in South Carolina)

  Major medical health insurance provides benefits up to a high limit for most types of medical expenses incurred, subject to a deductible. Once you meet the deductible, our South Carolina Major Medical Insurance plans pay a percentage of what is considered the "Usual and Customary" charge for covered services. The insurance company generally pays 80% of the Usual and Customary costs and you pay the other 20%, which is known as co-insurance. If the insurance company charges more than the Usual and Customary rates, you will need to pay both the co-insurance and the difference.   With South Carolina Major Medical Insurance plans you can choose your doctor and any hospital for your medical services. You or your doctor send the bill to the insurance company, which pays part of it. Usually, you have a deductible such as $250 or more to pay each year before the insurer starts paying. The plan will pay for charges such as medical tests and prescriptions as well as from doctors and hospitals.   Major medical insurance coverages offer more choice of doctors (including specialists, such as cardiologists and surgeons), hospitals, and other health care providers than managed care plans, such as HMO, PPO, and POS. South Carolina Major Medical Insurance may not pay for some preventive care, such as check-ups, and is usually a more expensive health insurance coverage than utilizing a South Carolina HMO, PPO, or POS plan.    

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