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Can I predict what your medical bills will be? In a good year, your costs may be low. But if you become ill, your bills could be very high. If you have insurance, many of your costs are covered by a third-party payer, not by you. A third-party payer can be a New Jersey insurance company or, in some cases, it can be your employer. What's a PPO? Health maintenance organizations are prepaid health plans. As an HMO member, you pay a monthly premium. In exchange, the HMO provides comprehensive care for you and your family, including doctors' visits, hospital stays, emergency care, surgery, lab tests, x-rays, and therapy. The HMO arranges for this care either directly in its own group practice and/or through doctors and other health care professionals under contract. Usually, your choices of doctors and hospitals are limited to those that have agreements with the HMO to provide care. However, exceptions are made in emergencies or when medically necessary. There may be a small copayment for each office visit, such as $5 for a doctor's visit or $25 for hospital emergency room treatment. Your total medical costs will likely be lower and more predictable in an HMO than with fee-for-service insurance. Because HMOs receive a fixed fee for your covered medical care, it is in their interest to make sure you get basic health care for problems before they become serious. HMOs typically provide preventive care, such as office visits, immunizations, well-baby checkups, mammograms, and physicals. The range of services covered in New Jersey vary in HMOs, so it is important to compare available plans. Some services, such as outpatient mental health care, often are provided only on a limited basis. Questions to Ask About a New Jersey HMO Are there many doctors to choose from in New Jersey? Do you select from a list of contract physicians or from the available staff of a group practice? Which doctors are accepting new patients? How hard is it to change doctors if you decide you want someone else? How are referrals to specialists handled? Is it easy to get appointments? How far in advance must routine visits be scheduled? What arrangements does the HMO have for handling emergency care? Does the HMO offer the services I want in the area of New Jersey I live? What preventive services are provided? Are there limits on medical tests, surgery, mental health care, home care, or other support offered? What if you need a special service not provided by the HMO? What's a PPO? The preferred provider organization is a combination of traditional fee-for-service and an HMO. Like an HMO, there are a limited number of NJ doctors and hospitals to choose from in the New Jersey area. When you use those providers (sometimes called "preferred" providers, other times called "network" providers), most of your medical bills are covered. Questions to Ask About a New Jersey PPO Are there many
doctors to choose from? Who are the doctors in the PPO network? Where
are they located? Which ones are accepting new patients? How are referrals
to specialists handled? What NJ hospitals are available through the PPO?
Where is the nearest hospital in the PPO network? What arrangements
does the PPO have for handling emergency care? What services are covered?
What preventive services are offered? Are there limits on medical tests,
out-of-hospital care, mental health care, prescription drugs, or other
services that are important to you? |
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