Managed Care - Details
Insurance companies have developed hundreds of different plans, all with different names, but most fall into 3 major categories. They are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point Of Service (POS) plans.
All of these plans typically offer financial incentives for patients to use the providers who belong to the plan. HMOs are generally the lowest cost but typically require you to use only participating providers (providers that are part of the plan). Exceptions are usually made for emergencies, but all other services and specialists need to be routed through your Primary Care Physician (PCP) . Primary Care Physicians may be family practice doctors, internists, pediatricians, or other types of doctors. The Primary Care Physician is responsible for referring you to specialists when needed. While most of these specialists will be participating providers in the HMO, there are circumstances in which patients enrolled in an HMO may be referred to providers outside the HMO network and still receive coverage.
Preferred Provider Organizations (PPO) and Point of Service (POS) plans are more flexible than most HMOs when you receive a covered service from a provider who is not in the plan. Of course, choosing a provider outside the plan’s network will cost you more than choosing a provider in the network. These plans will act like fee-for-service plans and charge you coinsurance when you go outside the network.
In most cases, POS plans have primary care physicians who coordinate patient care, and PPO plans do not.