HMO and POS Plan Differences
How do HMOs and POS plans work?
In managed care, including HMOs (health maintenance organizations) and POS (point-of-service) plans, you usually get care from a set group of doctors and hospitals that make up the plan's provider network. This differs from fee-for-service (indemnity) insurance, which does not have provider networks and permits you to get care from any doctor or hospital. However, fee-for-service insurance may have less predictable and higher out-of-pocket costs.
The table below highlights some of the important similarities and differences among HMOs, POS plans and fee-for-service. The table presents general rules. Be sure to check with your plan or employer to verify information.
This report only contains information on HMOs and POS plans in New Jersey.
|Can you get services from providers who are not in the network?||No. The HMO pays for covered services only if you go to providers in the network.||Yes. If you use providers who are not part of the network you will pay more.||Yes. You may receive care from any provider of your choice.|
|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 do not usually need to fill out claim forms.
|If you go to a provider who is in the network, there is no deductible and you are charged a co-payment. No claim forms need to be filled out. |
If the provider is not in the network, 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 a percentage of the cost of the covered services and the insurer pays the remaining costs. Usually, you pay 20% of the cost and the insurer pays 80%.|
|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 select a PCP from the list of network doctors.||No. You can get care from any doctor of your choice.|
|Do you need a referral from your PCP to go to 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 go to a specialist who is in the network.|
You do not need a referral to go to a specialist who is not in the network.
|No. You do not need a referral to go to a specialist.|