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2007 New Jersey HMO Performance Report
   
HMO and POS Differences


How HMO and POS Products Work

In traditional HMO products, you are required to obtain care from doctors and hospitals that are part of the HMO’s network, or your services will not be covered by the HMO. In POS (Point-Of-Service) products, you can use both in- and out-of-network doctors and hospitals, but you may pay more, if you use out-of-network providers. In traditional fee-for-service products, there is no network and you typically can go to any doctor or hospital, but your benefits are generally lower than what you would receive under most HMO or POS products.

This table compares traditional HMO, POS plans and fee-for-service insurance products. The table presents general information, which may not fully describe your plan. Be sure to check with your carrier or employer to verify information.

Traditional HMO POS Fee-for Service
Can you get covered services from providers who are not in the network?
No. The HMO pays for covered services only if you use network providers. In a medical emergency, the HMO will also pay for covered services from a non-network provider. Yes, but you usually pay more than if you go to a network provider. There is no network. You may get care from any provider.

How do you pay for services?

You are usually charged a co-payment (usually between $5 and $50) for a doctor’s office visit and most other services. You may or may not have to satisfy a deductible. HMOs may impose a coinsurance for some services. You usually do not need to fill out claim forms.

If you use a provider who is in the network, you typically pay a co-payment, but no deductible. You do not have to fill out claim forms.

If you use a provider who is not in the network: after you pay a deductible, you pay the coinsurance specified in your policy (which may range from 10–50%) and the insurer pays the rest up to the insurer’s allowed amount. If your provider bills more than the allowed amount, you also must pay the difference between the billed and allowed charges (balance billing). You may need to fill out a claim form.

After you pay a deductible, you pay the coinsurance specified in your policy (which may range from 10–50%) and the insurer pays the rest up to the insurer’s allowed amount. If your provider bills more than the allowed amount, you also must pay the difference between the billed and allowed charges (balance billing). You will need to fill out a claim form.

 

Do you need to choose a Primary Care Provider (PCP)?

You usually need to choose a PCP from the network, who takes care of most of your medical needs.

You usually need to choose a PCP from the network.

You do not need to choose a PCP.

Do you need a referral from your PCP to go to a specialist?

You usually need a referral, although in many HMOs some types of specialists may be available without a referral. Some HMO products allow visits to most specialists in the network without a referral.

Depends. You usually need a referral only if you want to see a specialist and receive in-network benefits. Some POS products allow visits to in-network specialists and provide in-network benefits without a referral.

If you use a provider who is not in the network, you usually do not need a referral, but you will pay more than if you go to in-network providers.

You do not need a referral to go to a specialist.

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New Jersey Department of Banking and Insurance