Ohio Med PPO network providers are physicians, hospitals and other medical providers that the third-party administrator, Medical Mutual, has selected and contracted to care for its members. Generally, network providers have agreed to undergo an extensive credentialing process, adhere to certain protocols and quality measures, and provide care and services at negotiated rates.

Non-network providers are physicians, hospitals and other health care providers who are not part of Ohio Med’s network. If you are in the Ohio Med PPO, you may use a non-network provider, but your costs will be significantly higher. That is because you will pay higher copayments and coinsurance, and non-network providers may not accept Ohio Med’s payment as payment in full. If that is the case, non-network providers may bill you the difference between their charges for services and the amounts Ohio Med allows, a process known as “balance billing.” To manage your costs, check with any non-network providers you use to see if they accept Ohio Med’s allowance as payment in full.

* These amounts do not include balance-billing from non-network providers.

Up to two Health Maintenance Organizations (HMOs) may be available to you depending on the county in which you live or work — see the map for availability. An HMO provides coverage and care through a network of physicians and hospitals.

If you enroll in Paramount, you need to select a primary care physician to provide and coordinate all care, including non-emergency services and specialist care. The Health Plan and QualChoice require you to choose a primary care physician, but you do not need to obtain a referral to see a specialist. Aetna and UnitedHealthcare do not require you to choose a primary care physician. Only in emergency situations does an HMO pay benefits for services received from non-HMO providers.

HMOs require little, if any, paperwork, and most services are covered at 80 percent with no deductible. Please note that you cannot change plans during the year if any of your providers leave your HMO.

The Role of Your
Primary Care
Physician

Your primary care physician coordinates your medical care. He
or she may act as your family doctor and can direct your treatment and referral
to specialists.

You must choose a primary care physician at the time you enroll in a plan that requires it — all plans except the Ohio Med PPO, Aetna and UnitedHealthcare require
you to select a primary care physician.

Employees enrolled in Paramount must obtain a referral from their primary care physician before they can visit a specialist. However, employees enrolled in The Health Plan and QualChoice can see a specialist without a referral from their primary care physician.

In all of the plans, women may access OB/GYNs without primary care physician referrals.

Refer to the Comparison Chart to see a side-by-side comparison of all the health plans.

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The Ohio Med Traditional Plan provides benefits at any out-of-state physician or hospital at the terms described in the box below. You may use network or non-network providers. However, use of non-network providers may be more expensive and you are not protected against balance-billing.

*To enroll in the Ohio Med Traditional Plan, you must use an Enrollment Form (ADM 4717). Enrolling in Ohio Med using the Web enrollment system will result in enrollment in the PPO.