Here are all the articles I've written about Health maintenance organization. Enjoy!

August 17th, 2016

“What’s Up, Doc?” Blog Series Part 11: All Better… But OUCH, This BILL!!

Oodles of gratitude for taking this virtual trip to the doctor with us!  Here’s even more in the series “What’s Up, Doc?”  Catch up with parts one, two, three, four, five, six, seven, eightnine, and ten.

And now, our last in the series… “All Better… But Ouch, THIS BILL!!”

  1. Your doctor is IN-network right?    The doctor’s office MUST submit the bill (aka “the claim”) directly to your insurance company.
  2. The IN-network doctor CAN ask you for the office visit co-pay at the time of the visit.    But, for medical services done during the visit…
  3. The IN-network doctor canNOT charge you until after the insurance company applies the IN-network discounts (the negotiated rate).
  4. When you get a bill from the doctor’s office, be sure that the IN-network discounts have been applied.   How do you know?
  5. … because you got an Explanation of Benefits (EOB) from the insurance company!   Check the EOB against the provider’s bill, and THAT’s how you know you’re getting the right discounts.
  6. If the doctor is OUT-of-network you’ll be submitting your own claims to your insurance company – and the doctor can charge you whatever she likes, there are no discounts.
  7. If you have an HMO, you must ONLY see a doc in your HMO group.  There are NO benefits in an HMO if you go to an out-of-network doctor.

Talk to me!  Was this helpful?  What was your fave piece of info?  Suggestions and thoughts are welcome.  And as always, reach out to us for any of your insurance needs.…

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April 13th, 2015

PPO, HMO, or EPO? What’s in a name?!

What’s with the alphabet soup?  What’s it all mean?  How will it inform your choices?

Understanding the differences in these 3 plan types is essential in understanding health insurance in this new wacky market.


Say your toe hurts and you’re on an HMO (aka Health Maintenance Organization.)  Where do you go first, the podiatrist?  WRONG!  With an HMO, you have to get prior approval and referral to a specialist from your PCP (Primary Care Physician.)   And, there are NO out-of-network benefits ever, except for emergencies.   HMO’s are a way for the insurance company to reduce costs by eliminating unnecessary testing and procedures by running everything by your PCP doctor.

At the end of the day, you have less control over your own medical care and it can be a time suck.


PPO’s (or Preferred Provider Organization) tend to have a richer doctor network and, by using these doctors, you get great price discounts.  But it’s up to you to make sure your fave docs are IN-network.  You can choose whatever doctors you like, whenever you like… no need for a PCP referral.

You can also choose to go to an OUT-of-network doctor, but you’ll pay more out of your own pocket.  These doctors don’t have to discount their fees and there may be a separate (and higher!) deductible for out-of-network services.

But if you like being in charge of your own medical destiny, this could be a great plan for you!

And the new weird one you may not be familiar with . . .


EPO stands for Exclusive Provider Organization.    An EPO network is a PPO-HMO mash-up.   Benefits are available only IN the EPO network.   Like a PPO network, you can pick and choose your own doctors at any time.   But, like an HMO, there are …

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February 13th, 2012

Get Cheap(er) Drugs!

The Insurance Mom wants YOU to be a good money manager, and here’s one tool you can use painlessly, immediately and easily.  And, best of all, it’s free!

MyRxSavings is a pretty cool prescription discount program.  Go to the site, print out your discount card and you’re off to the land of saving money!  You can even print out manufacturer’s discount coupons for some of your favorite drugs.     You’ll see coupons for as low as $4 for a 30-day supply of that expensive drug you’ve been taking for so long.

Instead of giving all of your money to the big pharma companies, let them pay for your drugs!   Be sure to read the fine print.  You can’t use the discount card or coupons in addition to discounts you may be already receiving from your health insurance plan or if you’re on Medicare.

Another great resource from me to you!…

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December 7th, 2011

Lipitor, be gone!

The Insurance Mom is thrilled to tell you how to save even more money on your prescriptions if you have those pesky cholesterol problems and have been taking — or are about to start taking — Lipitor.

The 17-year patent has finally expired… wahoo!  Now the drug is available in generic form.    Atorvastatin is the generic name to ask about at the doctor’s office or pharmacy.

Today’s health insurance plans usually have a “tiered” drug benefit.   Drugs on Tier 1 are the least expensive; most of them are generics.   Atorvastatin has been added to most formularies at the Tier 1 level, meaning they’re going to save you SO much money!

If your doctor insists that you continue to take the brand name drug Lipitor, well…   Tell your doctor you want him/her to pay for it!     Or give you free samples.    It’s been moved to Tier 3 in most formularies and is going to put a severe cramp in your monthly budget!

Fight for your money!  Spend less.  Use generic drugs.  It will not only cost you less but it will cost the insurance companies less too.  If we all insist on prescriptions for generics only, then the insurance companies spend less on ridiculously high-cost drugs and we could all have an impact on how insurance premiums rise every year.

And just think, if you’re spending less on prescriptions you’ll have more money available for sushi!…

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October 22nd, 2011

Wanna Save Some Money (part 3)?

Getting a prescription from your doctor doesn’t mean you don’t have choices about how to spend your money.

Ask your doctor if a generic drug is available and make sure it’s in the same class of drugs as the expensive brand name drug he wants to you to buy.

Generics have the same active ingredients, strengths and dose as the more expensive brand name versions.

A single manufacturer no longer holds the (17 year!) patent, so there’s more competition to keep the price down.

Tell your doctor that if he wants you to have a brand name drug, then spend his money not yours!  Or give you free samples.

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October 21st, 2011

Wanna Save Some Money (part 2)?

Need to get lab work done, such as blood or urine tests, PAP test or biopsy?

Think about using a lab that isn’t located in or part of a hospital.

They’re often way less expensive than a hospital lab, and some health insurance plans have a lower co-pay for outside labs.

And many outside labs have more flexible hours, like when you need to go early in the morning before your half-caf-half-decaf-low-fat-vanilla-with-a-hint-of-cinammon-latte.

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February 4th, 2010

Canada-Care’s Secret

You want medical care like Canada’s?   Are you sure?   Take a look … and now tell me, are you really sure?…

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January 19th, 2010

HMO News for Californians

It’s taken EIGHT years!   CA is finally revealing its new regulations specifying just how long your HMO doctor can make you wait for an appointment.  And it will be another 12 months before the provisions are implemented.    CA had to actually legislate how quickly HMO doctors must see their patients, return phone calls and take care of you in an emergency.   This reminds me of what happened in the UK 4 years ago, when it was legislated that wait times to see a primary care physician could be no longer than 13 weeks!!   No joke.   If you’re in CA and enrolled in an HMO, this is good news for you.  But I still think HMOs should be outlawed.

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