(HMO) Health Maintenance Organizations

A type of managed care organization (health plan) that provides health care coverage through a network of hospitals, doctors and other health care providers. Typically, the HMO only pays for care that is provided from an in- network provider. Depending on the type of coverage you have, state and federal rules govern disputes between enrolled individuals and the plan.

Advantages:

  • Low co-payments, minimal paperwork, and coverage for some preventive-care and health-improvement programs.

Disadvantages:

  • HMO requires that you see only network doctors, or they won’t pay.

POINT OF SERVICE (POS)

A health plan allowing the customer to choose to receive services from a participating (in-network) or non-participating (out-of-network) health care professional.

Advantages:

  • You may visit a doctor outside the network and still receive coverage; but substantially less than if you stayed within your network.

PREFERRED PROVIDER ORGANIZATION (PP0)

A type of managed care organization (health plan) that provides
health care coverage through a network of providers.

A specific type of ┬áhealth plan with a national network of physicians. Customers can visit physicians both in- and out-of-network, and can visit specialists without a referral. Customers don’t need to choose a primary care physician (PCP) for coverage. An annual deductible is usually required and an out-of-pocket maximum applies.

Give policyholders a financial incentive – reasonable co-payments (also called co-pays) – to stay within the group’s network of practitioners.

Advantages:

  • Having access to a larger national network of providers.
  • You may go to any specialist without permission, as long as the doctor participates in the network.

Disadvantages:

  • If you see an out-of-network doctor, you may have to pay the entire bill yourself, then submit it for reimbursement.
  • You may have to pay a deductible if you choose to go outside the network, or pay the difference between what network doctors charge vs. out-of-network doctor’s charge.

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