Insurance
Wizard - Plan Types
Traditional Plan |
Preferred Provider Organization (PPO)
Point of Service (POS) |
Health Maintenance Organization (HMO)
Traditional Plan:
- Freedom to choose providers
- Provider reimbursed on usual and customary fee-for-service basis
- Some services reviewed for medical appropriateness
- Member pays out-of-pocket for any provider fees not reimbursed in full
Preferred Provider Organization (PPO):
- Freedom to choose providers; no cutbacks when medical services received from preferred provider
- Benefits available outside PPO network; member pays higher deductible and/or coinsurance
- Preferred provider reimbursed according to negotiated fee schedule or discount
- Hospital admissions reviewed for medical appropriateness
- Preauthorization review for selected services
Point of Service (POS):
- Freedom to choose providers; no cutbacks when medical services received from POS network provider
- Benefits available outside POS network; member pays higher deductible and/or coinsurance
- POS network provider reimbursed according to negotiated fees, discounts, or monthly fee per patient
- Each POS enrollee selects a primary physican to coordinate care
- Hospital admissions reviewed for medical appropriateness
- Preauthorization reviews for selected services
Health Maintenance Organization (HMO):
- Provider choice limited to HMO network providers
- Limitations on access to mental health and chiropractic providers
- Formulary used to determine drug coverage
- HMO paid monthly fee per patient
- Each HMO enrollee selects a primary physican who coordinates care and approves referrals for speciality care
- Hospital admissions and most other services reviewed for medical appropriateness
- Limited coverage for care outside network
