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.
|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.|