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Health Maintenance Organizations
HMOs give you a list of doctors from which to choose a primary care physician (PCP). A PCP coordinates your care, which means that generally you must contact him or her to be referred to a specialist within your designated medical group. If you belong to an HMO, the plan only covers the cost of charges for services authorized by your PCP. HMOS only provide coverage for services outside of your medical group in cases of emergencies.
Point-of-Service Plan
This plan combines characteristics of the HMO and the PPO. The in-network level of this plan functions like an HMO and you must choose a primary care physician who is responsible for all referrals within the POS network. If you choose to go outside the network for healthcare, the plan functions more like a PPO.
Preferred Provider Organization (PPO)*
A PPO generally offers a broader network of doctors and hospitals than an HMO. This plan model has arrangements with doctors, hospitals, and other providers of care who have agreed to accept lower fees from the plan for their services and participate in the network of physicians. If you need or want heath care from outside the network you have access, but you should expect to pay a higher copayment than if the provider were from within the PPO network.
PPO with Health Reimbursement Account**
Anthem Lumenos is a high-deductible PPO plan with UC-provided health reimbursement account (HRA). With this plan you may choose any doctor or hospital you wish, but providers in the Anthem Blue Cross network cost less. You pay 100 percent of the cost of services, including prescription drugs, but costs are automatically deducted from your HRA first. If you use all of the HRA, then you pay all costs until you meet the deductible amount. Once you meet the deductible, you pay 20 percent for in-network services and 40 percent for out-of-network services. Preventive care from in-network providers has no charge
If you don’t use all of your HRA funds in a year, they roll over to the next year.
Behavioral health benefits are provided by United Behavioral Health. You can use your HRA to pay for these services, and costs are included in your deductible and out-of-pocket maximums.
Fee-for-Service Plan*
This plan allows you to choose the doctor, the hospital, the clinic, or the behavioral health provider and the insurance pays for part or all of the cost according to the schedule laid out in the policy after you have met your plan's deductible. Under this plan, you pay for services up front and submit a claim to the insurance company, and if the service is covered in the policy, you receive reimbursement.
To learn more about the similarities and differences among HMOS, Point of Service plans, PPOs and fee-for-service plans, see the Medical Plan Comparison chart.
To compare medical plans use the Medical Plan Chooser.
*Available to employees living outside of California
**Available to employees living in the U.S.
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