Understand how health insurance works.
MVP offers health plans in New York and Vermont for individuals, employers, Medicare, and more. And we know it can get confusing sometimes. So we’re here to help. Because the more you understand about health insurance, the better prepared you’ll be to make smart choices about your health care.
Why do I need health insurance?
When you have health insurance, you can take advantage of many preventive services, such as yearly physicals and regular screenings at no cost. This will help identify any concerns early and mitigate potential problems.
Health insurance is also important for protecting you financially in the case of major illness or health emergencies.
Where do I get health insurance?
There are a number of different ways to get health insurance. Your employer may offer it to you (and even cover a portion of your premium). Or, you can buy your own insurance—either directly through a company like MVP or via a health insurance exchange. In addition, government-sponsored programs such as Medicaid and Child Health Plus are available to those who qualify.
What do the different types of plans (HMO, PPO, etc.) mean?
You have many options to choose from when picking a health plan.
Health Maintenance Organization (HMO) Plans
With these plans you pay a monthly premium and often a co-pay when you receive medical care from a specified network of doctors and facilities. HMO plans do not typically cover medical expenses received from out-of-network providers. HMO plans often have higher premiums, but lower out-of-pocket costs.
What is an HMO Network?
- HMO plans typically feature a large, regional provider network. Most HMO plans require members to pay a co-pay, co-insurance or a deductible for certain medical services.
- Only visits to professionals within the HMO network are covered by the policy. All visits, prescriptions and other care must be cleared by the HMO in order to be covered.
- If your health plan ID card shows your plan type as an HMO, then we recommend you choose a Primary Care Physician (PCP). Your PCP acts as your “gatekeeper” and can refer you to specialists who participate in the MVP network of health care providers, as needed.
- You are not covered for out-of-network services except for Emergency Services and certain types of care that may not be available from a network provider (which would require prior authorization to determine coverage).
Preferred Provider Organization (PPO) and Exclusive Provider Organization (EPO) Plans
These plans allow you to choose care from health care providers in- or out-of-network. You will usually pay more if you receive care from a provider who is out-of-network.
What is an EPO/PPO Network?
- An EPO plan requires members to use providers from specified in-network providers to receive coverage. There is no coverage for care received from a non-network provider, except in an emergency situation. If a member receives care from a non-network provider, the member will pay the full cost of the services received. MVP PPO members use MVP’s network of preferred providers in the service area and use Cigna network providers outside of the service area.
- A PPO is an insurance plan offering members both in-network and out-of-network benefits. In-network providers, known as preferred providers, are physicians, hospitals and other health care providers who participate in the health plan’s network. MVP PPO members use MVP’s network of preferred providers in the service area and use Cigna network providers outside of the service area. Members who receive covered services from non-preferred providers will pay higher out-of-pocket costs.
High-deductible Health Plans (HDHP)
Plans like these usually have lower monthly premiums, but you’ll have to pay out-of-pocket for everything (other than preventive care) until you hit your deductible. After that, the insurance will pay benefits based on that particular plan’s co-insurance level.
You may be able to take advantage of special funding options, such as a Health Savings Account or Health Reimbursement Arrangement, with pre-tax dollars to help offset your deductible.
What do “in-network” and “out-of-network” mean?
An in-network health care provider is one contracted with MVP to provide services to members for specific pre-negotiated rates.
An out-of-network provider is one not contracted with MVP.
Typically, if you visit a physician or other provider in-network, the amount you will be responsible for paying will be less than if you go to an out-of-network provider.
Though there are some exceptions, in many cases, MVP will either pay less or not pay anything for services you receive from out-of-network providers.
Why use MVP in-network providers and facilities?
- MVP has made arrangements with a large number of physicians, hospitals, laboratories and other health care organizations to provide services to our members. If you have an HMO plan, for example, you must use providers who are part of our network.
- When medically necessary, the MVP Medical Director may make arrangements for members to receive care from non-participating physicians and/or hospitals. In such cases, prior written approval must be obtained.
- MVP will cover emergency care for members at non-participating hospitals or health care facilities, but you must seek any necessary follow-up care from MVP providers. If you have an EPO/PPO plan and go to a provider out-of-network, you may pay more for their services.
How do I find out if my doctor is in the MVP network?
Prior authorization is the approval that your doctor must get from MVP before you receive certain outpatient, home care and professional services, as well as certain prescription drugs. It also is the approval that you need from MVP before you receive any services from a non-participating (“out-of-network”) health care provider.
Review the services requiring Prior Authorization (PDF).
When can I change my health plan?
Most people have the opportunity to change health plans once a year during the Annual Election Period (also called Open Enrollment). Open Enrollment usually runs from early November through late January.
You may also be able to change or enroll in a plan if you experience a qualifying life event, such as a marriage/divorce, birth of a child, loss of job, or move.
Confusing terms? Search our Glossary.
Need help with unfamiliar health insurance words or phrases? Check out the MVP Health Care Glossary to help you understand more about your health plan, coverage, benefits, or to help you shop for a plan.
Questions on financial assistance?
Learn what programs you might be eligible for.