Medical Coverage
Using an EPO Plan An Exclusive Provider Organization (EPO) is a health insurance plan that only allows you to get health care services from doctors, hospitals, and other care providers who are within a certain network. Your insurance will not cover any costs you get from going to someone outside of that network. The only exception is that emergency care is usually covered. • EPO plans only cover the cost at doctors or health provid- ers that are within your network • Emergency care is covered, even if it’s out of your network • You do not need a referral if you want to see a specialist with EPO insurance • An EPO is a hybrid between an HMO and PPO plan Using a PPO Plan A Preferred Provider Organization allows you to see physicians both in network and out of network. You will pay a different coinsurance to see doctors and/or hospitals outside of the network. • You do not need to select a PCP, nor do your dependents • Be sure to ask your physician/hospital if they are “in- network” to take advantage of the lower coinsurance • You do not need a referral to see a specialist. You may see any physician in network or a physician who agrees to bill out of network • Services may require a copay up front • If your physician does not bill the carrier directly, you may submit claim forms for reimbursement if services are medically necessary
Whether you have a common cold or will be undergoing surgery, medical benefits cover a range of services and can provide peace of mind to help you offset health care costs. Your Medical Plan Options The medical options available through Pacific Personnel Services are from Anthem Blue Cross. To help guide your plan selection, the following pages include details concerning how the plans will operate, as well as plan highlights and features. For your reference, an illustration of rates is listed in The Cost A Health Maintenance Organization (HMO) plan requires you and enrolled dependents to select a Primary Care Physician (PCP) who will direct the majority of your health care needs. Generally, an HMO operates as follows: • With an HMO you must select a PCP from within network • You and your enrolled dependent(s) are not required to see the same PCP, and you may change your PCP at any time of Coverage section of the guide. Using an HMO Plan • With the exception of an OB/GYN specialist who is affiliated with your selected medical group, you must receive a referral from your PCP before receiving services from a specialist • Any services rendered out-of-network without the proper referral from your PCP will not be covered. • Services may require a copay up front • You do not have to submit claim forms to your insurance company
Benefits Guide 2024-25 5
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