2001 NJ HMO Performance Report

	Cover Letter
	Quality Matters
	Performance Summary
	Service and Access
	Doctors and Medical Care
	Staying Healthy
	Getting Better /Living with Illness (Part 1)
	Getting Better /Living with Illness (Part 2)
	Choosing Your Health Plan
	Taking Responsibility forYour Health Care
	Contacting Your Health Plan
	Appeals and Complaints
	Other Important Resources
	HMOs and POS Differences
	Consumer Bill of Rights
	Return to Cover Page
	Performance Report (PDF)
	Plan Comparison Tool Allows you to choose specific plans for comparison

HMOs and POS Differences

How HMOs and POS Products Work?

In HMO (Health Maintenance Organization) and POS (Point-Of-Service) products, 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 HMO, POS plans and fee-for-service insurance. The table presents general information, 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 than if you go to a network provider. 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 office visit 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. 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 coinsurance (usually 20–40%) 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 coinsurance (usually 20–30%) 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 can get care from any doctor.

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 innetwork specialists and provide innetwork 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.

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 than if you go to a network provider.	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 office visit 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. 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 coinsurance (usually 20–40%) 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 coinsurance (usually 20–30%) 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 can get care from any doctor.
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 innetwork specialists and provide innetwork 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.