Basic Information about HMO, PPO, and POS Plans - Medical Billing

HMOs
A health maintenance organization (HMO) is a type of managed healthcare system. HMOs, preferred provider organizations (PPOs), share the goal of reducing healthcare costs by focusing on preventative care and implementing utilization management controls.
Unlike many traditional insurers, HMOs do not merely provide financing for medical care. The HMO actually delivers the treatment as well. Doctors, hospitals, and insurers all participate in the business arrangement known as an HMO.
HMOs provide medical treatment on a prepaid basis, which means that HMO members pay a fixed monthly fee, regardless of how much medical care is needed in a given month. In return for this fee, most HMOs provide a wide variety of medical services, from office visits to hospitalization and surgery. With a few exceptions, HMO members must receive their medical treatment from physicians and facilities within the HMO network. The size of this network varies depending on the individual HMO.
When you join an HMO, you choose a primary care physician (PCP) who is your first contact for all medical care needs. The primary care physician provides your general medical care and must be consulted before you can see a specialist. Because of this control system, HMO costs tend to increase less rapidly than other insurance plans.
Advantages of HMOs
Low out-of-pocket costs
With most types of insurance, you are responsible for paying a percentage of the bill every time you receive medical care. Additionally, there may be a deductible that must be met before insurance starts picking up the tab. In contrast, HMO members pay a fixed monthly fee, regardless of how much medical care is needed in a given month. Instead of deductibles, HMOs often have nominal co-payments.
Focus on wellness and preventative care
By reducing out-of-pocket costs and paperwork, HMOs encourage members to seek medical treatment early, before health problems become severe. Additionally, many HMOs offer health education classes and discounted health club memberships.
Typically no lifetime maximum payout
Unlike most health insurance plans, HMOs generally do not place a limit on your lifetime benefits. The HMO will continue to cover your treatment as long as you are a member.
Disadvantages of HMOs
Tight controls can make it more difficult to get specialized care
As an HMO member, you must choose a primary care physician (PCP). Your PCP provides your general medical care and must be consulted before you seek care from another physician or specialist. This screening process helps to reduce costs both for the HMO and for HMO members, but it can also lead to complications if your PCP doesn't provide the referral you need.
Care from non-HMO providers generally not covered
Except for emergencies occurring outside the HMO's treatment area, HMO members are required to obtain all treatment from HMO physicians. The HMO will not pay for non-emergency care provided by a non-HMO physician. Additionally, there may be a strict definition of what constitutes an emergency.
PPOs
Like an HMO, a preferred provider organization (PPO) is a managed healthcare system. However, there are several important differences between HMOs and PPOs.
A PPO is actually a group of doctors and/or hospitals that provides medical service only to a specific group or association. The PPO may be sponsored by a particular insurance company, by one or more employers, or by some other type of organization. PPO physicians provide medical services to the policyholders, employees, or members of the sponsor(s) at discounted rates and may set up utilization control programs to help reduce the cost of medical care. In return, the sponsor(s) attempts to increase patient volume by creating an incentive for employees or policyholders to use the physicians and facilities within the PPO network.
Rather than prepaying for medical care, PPO members pay for services as they are rendered. The PPO sponsor (employer or insurance company) generally reimburses the member for the cost of the treatment, less any co-payment percentage. In some cases, the physician may submit the bill directly to the insurance company for payment. The insurer then pays the covered amount directly to the healthcare provider, and the member pays his or her co-payment amount. The price for each type of service is negotiated in advance by the healthcare providers and the PPO sponsor(s).
Advantages of PPOs
Free choice of healthcare provider
PPO members are not required to seek care from PPO physicians. However, there is generally strong financial incentive to do so. For example, members may receive 90% reimbursement for care obtained from network physicians but only 60% for non-network treatment. In order to avoid paying an additional 30% out of their own pockets, most PPO members choose to receive their healthcare within the PPO network.
Out-of-pocket costs generally limited
Healthcare costs paid out of your own pocket (e.g., deductibles and co-payments) are limited. Typically, out-of-pocket costs for network care are limited to $1,200 for individuals and $2,100 for families. Out-of-pocket costs for non-network treatment are typically capped at $2,000 for individuals and $3,500 for families.
Disadvantages of PPOs
Less coverage for treatment provided by non-PPO physicians
As mentioned previously, there is a strong financial incentive to use PPO network physicians. For example, members may receive 90% reimbursement for care obtained from network physicians but only 60% for treatment provided by non-network physicians. Thus, if your longtime family doctor is outside of the PPO network, you may choose to continue seeing her, but it will cost you more.
More paperwork and expenses than HMOs
As a PPO member, you may have to fill out paperwork in order to be reimbursed for your medical treatment. Additionally, most PPOs have larger co-payment amounts than HMOs, and you may be required to meet a deductible.
POS plans
A Point of Service (POS) plan is a type of managed healthcare system that combines characteristics of the HMO and the PPO. Like an HMO, you pay no deductible and usually only a minimal co-payment when you use a healthcare provider within your network. You also must choose a primary care physician who is responsible for all referrals within the POS network. If you choose to go outside the network for healthcare, POS coverage functions more like a PPO. You will likely be subject to a deductible (around $300 for an individual or $600 for a family), and your co-payment will be a substantial percentage of the physician's charges (usually 30-40%).
Advantages of POS plans
Maximum freedom
POS coverage allows you to maximize your freedom of choice. Like a PPO, you can mix the types of care you receive. For example, your child could continue to see his pediatrician who is not in the network, while you receive the rest of your healthcare from network providers. This freedom of choice encourages you to use network providers but does not require it, as with HMO coverage.
Minimal co-payment
As with HMO coverage, you pay only a nominal amount for network care. Usually, your co-payment is around $10 per treatment or office visit. Unlike HMO coverage, however, you always retain the right to seek care outside the network at a lower level of coverage.
No deductible
When you choose to use network providers, there is generally no deductible. Thus, coverage begins from the first dollar you spend as long as you stay within the POS network of physicians.
No "gatekeeper" for non-network care
If you choose to go outside the POS network for treatment, you are free to see any doctor or specialist you choose without first consulting your primary care physician (PCP). Of course, you will pay substantially more out-of-pocket charges for non-network care.
Out-of-pocket costs limited
Healthcare costs paid out of your own pocket (i.e., deductibles and co-payments) are typically limited. The average yearly limit for individuals is around $2,400. For families, the average yearly limit is approximately $4,000.
Disadvantages of POS plans
Substantial co-payment for non-network care
As in a PPO, there is generally strong financial incentive to use POS network physicians. For example, your co-payment may be only $10 for care obtained from network physicians, but you could be responsible for up to 40% of the cost of treatment provided by non-network doctors. Thus, if your longtime family doctor is outside of the POS network, you may choose to continue seeing her, but it will cost you more.
Deductible for non-network care
In most cases, you must reach a specified deductible before coverage begins on out-of-network care. On average, individual deductibles are around $300 per year, and the average annual family deductible is about $600. This deductible amount is in addition to the co-payment for out-of-network care.
Tight controls to get specialized care
As in an HMO, you must choose a primary care physician (PCP). Your PCP provides your general medical care and must be consulted before you seek care from another doctor or specialist within the network. This screening process helps to reduce costs both for the POS and for POS members, but it can also lead to complications if your PCP doesn't provide the referral you need.