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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 the plan
pays less, and you 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 health plan 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. |
Yes. You may get care from any provider. |
| How do you pay for
services? |
You are usually charged a copayment (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 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 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.
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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.
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You do not need a referral to go to a specialist. |
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