HMO, "Health Maintenance Organization" - gatekeeper required with directory of physician and hospitals for In-network benefits only, NO out-of-network benefits.

POS, "Point of Service", - gatekeeper required, with directory of physician and hospitals for In-network benefits, includes out-of-network benefits after satisfaction of a deductible and coinsurance. Referrals are necessary from the gatekeeper in order to utilize In-network specialists.

POS/NGP, "Point of Service / Non Gatekeeper Plan" - Open access, is the same as POS, however no referrals are necessary to utilize In-network specialists.

PPO, "Preferred Provider Organization", - NO gatekeeper necessary, may go to any physician in the network without a referral, includes out-of-network benefits after satisfaction of a deductible and coinsurance.

EPO, "Exclusive Provider Organization", - No gatekeeper necessary, may go to any physician in the network without a referral. In-network benefits only, there are No out-of-network benefits.

All Hospitals in a PPO network are considered In-Network no matter who admits the insured. Admittance to a Hospital, can be made by a Participating provider or a Non Participating provider. In a POS/NGP, for the hospital to be considered IN-Network, only a Participating provider may admit an insured to the hospital.

A gatekeeper (PCP) is utilized under HMO and POS plans. This is the primary care physician of the insured. The insured is responsible to secure all referrals to a specialist, from their PCP.

The amount of money the insured must pay to the In-network doctor, the insured's cost sharing of the treatment.

The initial amount the insured pays before any reimbursement is made for out-of-network procedures. This applies to all POS, POS/NGP and PPO plans.

The amount the insured must pay in addition to what the insurance company pays. It is the sharing of the cost of medical care.
Example when an insured goes to an out of network doctor: After the insured deductible is meet; if the insured has 70/30 co-insurance, the insured would pay 30% of the cost, up to the stop loss.

The maximum amount the insured would pay.
Example: If the insured has a 70/30 of 5,000, the maximum amount the insured would pay under co-insurance is 30% of $5,000 or $1,500.

UCR stands for usual and customary reimbursement for a particular geographic area.

Two tier rates are based on Single/Family combinations and any one enrolling other than Single will pay the family rate. Four tier rates have a combination of Single / Parent & Child(ren) / Employee & Spouse / Family. Rates for four tier are based on the status upon enrollment and offer lower rates for the two middle tiers, while being higher for the family.

Many carriers offer allow a company to offer a high and low option for their employees. Usually you must have at least 10 employees to offer two plans, please contact us for further information.

Horizon Blue Cross -NJ
Horizon Health Care -NY
* Please remember to review our deadlines to FILCO requirement.

Aetna/US Healthcare
CIGNA Healthcare
GHI- Flex Select
Guardian/PHS
Health Pass
HIP
Oxford -POS NJ
Oxford - POS NY
United Healthcare - Select
United Healthcare - Choice +
* Please remember to review our deadlines to FILCO requirement.