What is the difference between an HMO, PPO and POS?

Answer 1

WHEEEEEEW this is a hard question. Ok one by one. First a PPO, this is what I have. With this insurance you have the most freedom. You don't have to wait for you family doctory (primary care physician) to refer you to a specialist. All you do is look at your book, that your employer or the insurance gives you and call them, and make an apointment. If you go by the physycians in the book your insurance will pay at a higher "contracted rate". What THIS means is, your insurance may not pay 100 percent of the office visit of any doctor except maybe physicals and basic things like that. But, if you choose a fairly descet one, your insurance could be 80/20 or 90/10 (just an example). What this means is that your doctor may bill the insurance 250 dollars for a doctors visit but what the insurances contract with them says they pay 120 of that 250 dollars, what you pay is 20 or 10 percent of that. You can go "out of network" but your insurance will not pay as much, that's why it pays to stay withing the network of doctors that are contracted with what ever insurance it may be. Some PPOs have a copay, some you just pay your percentage. But this PPO has the most freedom. You choose you primary doctor, you have a problem with your stomach and your primary doctor isn't helping, you just send yourself to a gastroenterologist(stomach doctor). I like this one!

Ok, POS, the second best. The good thing with this is, you can use it as both. But, it can be a little tricky. Ok, you can use it as a PPO or an HMO, BUT, if you happen to go to a doctor such as a Primary Doctor or a specialist who is in the medical group (not contracted but in the medical group (( i'll explain)) you HAVE to use it as an HMO and most likely will require referrals. Meaning you primary doctor will need to refer you for any specialty doctor. If you have a Doctor you like and he is not in your book, it's ok, you can use the ppo part of it. Lets say you go to a dermatologist, and they look at your card, say it says it is part of...ex:Beaver Medical Group, and they are in that medical group, then you will need a referral. I know a little confusing. But if you go to one that is not in the book, or contracted in the medical group you use the ppo. (i'll explain medical groups) But once you read more on this it's actually quite nice, more flexability then an HMO, but not as much as a PPO. If you don't have too many health issues to deal with, this isn't bad.

Ok... the dreadful HMO!!!!! Ok, first thing, HMO's you always have a copay. You see your primary doctor, copay. Dermatologist-copay not just that but you need a referral. You see any specialist you need a referral. You have a medical group that pretty much dictates what you can do and what you cant. A medical group...Ok, an HMO is something like, BLUE CROSS HMO (ex) and this HMO blue cross assigns a group that gets authorizations for referrals, for procedures, for surgeries for pretty much anything, even prescriptions. If the medical group feels its not necessary or there is something less expensive they can do they will recommend that first. Even if your primary doctor is referring you to a specialist, the medical group will recommend things like (say the primary doctor recommends a dermatologist) the medical group will say, has he tried this medication, or that one... they have to go by a protocall or things first. If all those methods or treatments have not been done, then they probably won't authorize it. Also say you go to a specialist and they recommend an inhouse (in office) procedure, with a PPO more or likely they do it then and there if possible. With an HMO they have to reschedule that, submit for authorization, have to wait till it's authorized by the medical group and if it is then they will notify the doctor. This HMO is ok, if you don't get too sick. Its cheap and if you just see a doctor for colds, flu, basic stuff then not too bad, just alot of hurdles alot of waiting alot of just not knowing what the medical group is going to say. May I say, the medical group is not a group of doctors either, it's just group of people who work for the HMO medical group that is with your insurance.

WHEW... i'm tired, I hope this helps, this is a small rundown but its just a breakdown of the overall picture. Hope if helps!

Answer 2

HMO = Health Management Organization
PPO = Preferred Provider Organization
POS = Point Of Service

HMO's tend to cost less, but have more restrictions, such as limited number of physicians, gate keepers (you must go to your primary doctor and get a referral to a specialist like an orthopedic)
POS are HMO's with a greater selection of providers
PPO's offer the greatest flexibility but usually cost more. You have the freedom of seeing specialists without having to get a referral or for the insurance carrier to approve the majority of services.

Also, pre-existing conditions are usually not covered through the HMO's (there are exceptions).

It's best to do your homework on this, and if you already have doctors that you see and you are now changing insurance, check to see if your doctors take the new plan.
HMO's might not have deductibles, but the out of pocket might be as much if not more than PPO plans that have deductibles.
For instance, we have the option of either at my co. but the HMO emergency room visit is $200, the PPO, $50.

Do the research, ask the questions. If you are doing this through work, talk to your benefits administrator to see what best fits your needs. If you are doing this on your own, research the net and ask all the questions you can and want to with the companies you are interested in.

Answer 3

They're all considered managed care--which means you, the subscriber, are limited in choices of physicians. It's not as bad as it sounds. Doctors and hospitals are contracted with many if not all of the plans in your region.

1. HMO: A Health Maintenance Organization, or HMO, provides employers a way to take care of all their employees’ health care needs with reduced costs by negotiating with specific doctors, hospitals, and clinics. These specific providers must be used by the employee for the reduced fees to be provided to their medical insurance plan.

2. PPO: In a Preferred Provider Organization, or PPO, an employer can also provide employees with reduced costs billed to their health insurance plan. Similar to a HMO, but the employees can choose the physician they want to see instead of being solely restricted to the HMO providers. An employee can choose between a member or nonmember provider. The member provider would be the least expensive choice for the employee.

3. POS: With a Point of Service plan, or POS, employees can choose their own physician that has previously agreed to provide services at a discounted fee. In a POS the employee would have to use the chosen physician as a gateway first before moving on to a specialist. In other words, whenever the employee would have a medical issue the POS physician must be contacted first in order to obtain the most benefit from the health insurance plan.

All managed care plans vary greatly in benefits and out of pocket expenses, so it is important to review your health insurance and medical insurance choices wisely and try to find the best policy to fit your circumstances.

http://personalinsure.about.com/cs/healthinsurance1/a/aa011704a.htm

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That being said, I personally prefer anything but HMOs. You have the inconvenience of referrals, pre-authorizations, and capitations with specialists.

Answer 4

HMO: (A Health Maintenance Organization) provides employers a way to take care of all their employees’ health care needs with reduced costs by negotiating with specific doctors, hospitals, and clinics. They have a list of specific providers that must be used by the employee for the reduced fees to be provided to their medical insurance plan. Whenever the employee would have a medical issue the HMO physician must be contacted first in so he can get you to the right specialist (Cardiologist, internist, etc.). Failure to do so will cost you payment in full when you see the specialist by yourself.

PPO (In a Preferred Provider Organization) an employer can also provide employees with reduced costs billed to their health insurance plan. Similar to a HMO, but the employees can choose the physician they want to see instead of being solely restricted to the HMO providers. An employee can choose between a member or nonmember provider. The member provider would be the least expensive choice for the employee.

POS (With a Point of Service plan) employees can choose their own physician that has previously agreed to provide services at a discounted fee. In a POS the employee would have to use the chosen physician as a gateway first before moving on to a specialist. In other words, whenever the employee would have a medical issue the POS physician must be contacted first in order to obtain the most benefit from the health insurance plan.

Answer 5

HMO (you must get your medical care from that particular HMO group of physicians). HMO is excellent for new parents provided you select an excellent pediatrician per word of mouth. PPO is similar than HMO but you have a choice of getting health care from non-PPO physicians at a lower covered rate. POS gives selectivity but they office co-payments and pharmacy co-payments tend to be greater than HMO or PPO.

Your primary physician coordinates your preventive health care so select him/her carefully.

All plans are good if you know your benefits and use them to your advantage. In my opinion there are 3 most important physicians: pediatrician for kids, ob-gynecologist for females and urologist for males. Find your most important and significant physician in whichever plan he is enrolled and that is probably your best option. If any further ???? call Blue Cross & Blue Shields for detailed information. They have excellent service representatives.