Patient Resources

Insurance Participation

At Stone Springs Family Medicine we participate in many managed care plans and see patients with traditional insurance. See the detailed list of plans to the left. Many plans require that you make a co-payment at the time of your visit. To make it as easy as possible for you, we accept cash, checks, and most major credit cards at our office.

When making your appointment please provide us with insurance coverage updates.

Unfortunately we are not accepting new patient with Tricare or Medicare insurance at this time.

If you have any questions, please call our office at 703.766.5040.

Choosing the Health Plan That’s Right for You

Most every insurance company offers a wide range of health plans. But choosing the best plan for you can be challenging. Not all plans include the same doctors, hospitals, or care providers. Not all plans pay for the same services. Out-of-pocket costs vary. With so many options, how do you know which one is right for you?

Below is a quick and easy guide to help you find a healthcare plan that fits your needs.


Managed Care Plans

Health Maintenance Organization (HMO)

In an HMO, you get all your care from providers in your plan’s network. After you enroll, you’ll select a primary care provider (PCP) who coordinates your care and refers you to specialists if needed.

Most HMOs do not require a deductible, so your out-of-pocket costs are typically lower than with other plans as long as you stay in the network. If you receive out-of-network care, you will most likely have to pay the full cost of the doctor visit or service. Make sure your HMO has the range of providers you need to stay in-network for your care.

HMO networks are usually limited to a specific geographic region. They may employ their own doctors, contract with a specific group practice, or contract with many different providers in many different practices.

An HMO is right for you if: you want lower out-of-pocket costs and less paperwork, and your doctors already participate in the network.


Preferred Provider Organization (PPO)

In a PPO, you can use providers inside or outside of your plan’s network. You don’t have to choose a PCP or get referrals to see specialists. But if you do go out-of-network, your costs will be higher.

When you stay in-network, you will generally have to pay a co-payment or a percentage of the cost of the visit. When you go out-of-network, you will usually have to pay a higher deductible, as well as a higher percentage of the cost of the visit.

Most PPOs contract with a wide range of doctors, specialists, hospitals and other providers, so you’ll have a lot of choices.

A PPO is right for you if: you want the flexibility to visit a range of providers without getting a referral first.


Point of Service (POS) Plan

A POS plan is a combination of an HMO and PPO. Like an HMO, you select a PCP to coordinate your care and refer you to specialists if needed. Like a PPO, you can use providers inside or outside the network.

If you opt for out-of-network care, your costs will be higher. You won’t have to pay the full amount of each visit or service, but you’ll pay a bigger share. In addition, you’ll need to pay the provider yourself, and then submit the claim to your insurer for reimbursement.

A POS plan is right for you if: you want lower up-front costs, less paperwork, and the option of going out-of-network if you need to. It’s also a good choice if you spend part of the year living somewhere else.


Exclusive Provider Organization (EPO)

An EPO functions like a PPO, with one important difference – if you go outside the network for care, you generally must pay the full cost of the service yourself. If you opt for an EPO, make sure it has the range of providers you need to stay in-network for care. EPOs offer the additional advantage of lower premiums because providers and insurers often negotiate favorable rates.

An EPO is right for you if: you want lower out-of-pocket costs and the flexibility to visit a range of providers without getting a referral first.


Tiered Plans

Be aware that some plans assign their in-network providers to tiers to encourage members to see the most cost-effective doctors and specialists. So, even if you stay within the network, you may have to pay more. This is similar to prescription plans that charge a lower co-pay for generic vs. brand-name drugs.

In a tiered system, you may pay $25 to see a doctor in Tier 1, $35 in Tier 2, and $45 in Tier 3. When considering plans, be sure to ask about tiers and confirm which one your doctor is in.


Emergency Care

Many plans cover some portion of emergency care no matter where you are, even if it’s out of their network area. Once your condition is stable, you will be moved to an in-network provider.

However, this applies to real emergencies only. Never go to the emergency room for routine care, such as check-ups or vaccinations. Emergency room visits are very expensive and insurers only cover the cost of a true emergency. If you’re not sure what constitutes an emergency, ask your insurer or check your plan documents.


Questions to Consider

Before choosing a plan, answer these questions:

  • Are all your current doctors in the network?
  • What hospitals are your doctors affiliated with? Are they in the network, too?
  • Are providers in the network close to where you live and work?
  • Is the plan tiered? How much will you have to pay for providers in each tier? Which tier are your doctors and their affiliated hospitals in?
  • Are referrals or prior authorization necessary for some types of care?

Every plan must provide a complete description of its coverage, requirements, and limitations. This information is often available on your insurer’s website. Read it carefully and ask questions if there’s anything you don’t understand.