2000 NJ HMO Performance Report

	Quality Matters
	Performance Summary
	Service and Access
	Doctors and Medical Care
	Staying Healthy
	Getting Better / Living with Illness
	Getting Better / Living with Illness (Part 2)
	Choosing Your Health Plan
	Taking Responsibility for Your Health Care
	Contacting Your Health Plan
	Other Important Resources
	Appeals and Complaints
	Consumer Bill of Rights
	Return to Cover Page
	Plan Comparison Tool

HMOs and POS Plan Differences

How HMOs and POS plans work?

In HMOs (health maintenance organizations) and POS (point-of-service) plans, you usually get care from doctors and hospitals that are part of the plan's provider network. This differs from fee-for-service insurance, which permits you to get care from any doctor or hospital, but may have higher out-of-pocket costs.This table compares HMOs, POS plans and fee-for-service insurance. The table presents general rules, which may not apply to your plan. Be sure to check with your health plan or employer to verify information.

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. Yes, but you usually pay more. Yes. You may get care from any provider.

How do you pay for services? You are charged a copayment (usually between $5 and $25) for a doctor's officevisit and most other services. There is no deductible.
You usually do not need to fill out claim forms.
If you use a provider who is in the network, you pay a copayment, but no deductible. No claim forms need to be filled out.
If you use a provider who is not in the network, then you pay a deductible and a greater portion of the costs. You may need to fill out a claim form.
After you pay a deductible, you pay Coinsurance (usually 20-30%) and the insurer pays the rest.
You will need to fill out a claim form.

Do you need to choose a primary care provider (PCP)? Yes. You usually need to choose a PCP from the network, who takes care of most of your medical needs. Yes. You usually need to select a PCP from the network. No. You can get care from any doctor.

Do you need a referral from your PCP to go to a specialist? Yes, although some specialists may be available without a referral. Depends. You need a referral only if you want to see a specialist and receive in-network benefits. No. You do not need a referral to go to a specialist.

	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.	Yes, but you usually pay more.	Yes. You may get care from any provider.
How do you pay for services?	You are charged a copayment (usually between $5 and $25) for a doctor's officevisit and most other services. There is no deductible. You usually do not need to fill out claim forms.	If you use a provider who is in the network, you pay a copayment, but no deductible. No claim forms need to be filled out. If you use a provider who is not in the network, then you pay a deductible and a greater portion of the costs. You may need to fill out a claim form.	After you pay a deductible, you pay Coinsurance (usually 20-30%) and the insurer pays the rest. You will need to fill out a claim form.
Do you need to choose a primary care provider (PCP)?	Yes. You usually need to choose a PCP from the network, who takes care of most of your medical needs.	Yes. You usually need to select a PCP from the network.	No. You can get care from any doctor.
Do you need a referral from your PCP to go to a specialist?	Yes, although some specialists may be available without a referral.	Depends. You need a referral only if you want to see a specialist and receive in-network benefits.	No. You do not need a referral to go to a specialist.