Resource Center

Corporate Medical I. What are the differences between HMO, POS and PPO? HMO is an in-network only plan and usually requires a primary care doctorýs referral. POS has both in-network benefits and out of network benefits. The in-network benefits require a primary care doctorýs referral. The out of network benefits have a calendar year deductible, a greater coinsurance percentage and a greater out-of-pocket. PPO has both in network benefits and out of network benefits. The out of network benefits have a greater coinsurance percentage and greater out-of-pocket. II. If a portion of the calendar year deductible is satisfied in the last three months of the year can this amount be credited to the following yearýs deductible? Yes. This is a state mandate which is referred to as "Three Month Carry Over" If I have had continuous medical coverage for the last twelve months prior to being covered by my employerýs plan, should I be concerned about pre-existing conditions? No. Pre-existing conditions becomes an issue when more than a 90 day gap in coverage exists. III. When can an employee be added to our group health plan? The Regular Enrollment Date follows the groupýs standard employee eligibility period. The Open Enrollment Date is the annual renewal date of the employer's group insurance contract. The employee's Special Enrollment Dates are marriage, divorce, birth of a child and/or an involuntary loss of medical coverage. IV. For a terminated employee, do we use Georgia Continuation or Federal-COBRA? Georgia Continuation applies when the employer has had less than twenty employees for six months in the prior calendar year. COBRA applies when the employer has had twenty or more employees for at least six months in the prior calendar year. V. How do health plan benefits apply when two group insurance policies are eligible? This issue is called "Coordination of Benefits".                     The health plan is primary for its own subscribers, secondary for the spouse of its subscriber, and for children of married, non-separated parents, the plan of the parent whose birthday falls earlier in the year is primary. For children of separated or divorced parents, either a court order will stipulate responsibility for health coverage, or in the absence of a court decree, the plan of the natural parent with custody is primary, the plan of the spouse of the natural parent with custody is secondary, and the plan of the natural parent without custody is third. Plans covering a subscriber through active employment are primary to plans covering the subscriber as a retiree. Finally, as a tie-breaker, plans that have been in effect longer are primary over plans in effect for a shorter period of time.