NJ DHSS New Jersey HMOs: How HMOs and POS Plans Work

1998 New Jersey Managed Health Care Plans
How HMOs and POS Plans Work

This booklet contains information on two types of managed care plans in New Jersey: HMOs and POS plans. HMOs and POS plans deliver health care using provider networks, which are the groups of doctors, hospitals and other health care providers that serve people in a specific health plan.
HMOs generally pay only for services given by providers in the network. POS plans allow members to seek care from providers not in the network, but these services cost more. The table below highlights some of the important similarities and differences between HMOs and POS plans.

	HMO	POS
Can you get services from providers who are not in the network?	No. The HMO pays for all covered services only if you use providers in the network.	Yes. If you choose to use providers that are not part of the network you will pay more and fewer health services may be covered.
How do you pay for services?	There is no deductible. You are charged a pre-set amount or co-payment (usually between $5 and $25) for a physician office visit. You usually do not need to fill out claim forms.	If you use a provider who is in the network, there is no deductible and you are charged a co-payment. You do not need to fill out a claim form. If you use a provider who is not in the network, you may pay a deductible and a greater portion of the medical expenses. You may need to fill out a claim form.
Do you need to choose a primary care provider (PCP)?	Yes. You are usually required to choose a PCP from a list of network doctors. Your PCP takes care of most of your medical needs.	Yes. You usually need to choose a PCP from the list of network doctors. You have the option of using the PCP or going to a doctor who is not in the network.
Do you need a referral from your PCP to see a specialist?	Yes. Before you go to a specialist, you usually need a referral from your PCP.	Depends. You need a referral from your PCP only if you want to see a specialist who is in the network. You do not need a referral to see a specialist who is not in the network.