This plan is a managed care program that has two components: in-network benefits and out-of-network benefits. You receive the highest level of coverage when you receive in-network benefits. When you receive out-of-network benefits, you will incur higher out-of-pocket expenses. You will be responsible for meeting an annual deductible before services are reimbursed and paying a fixed percentage coinsurance amount or co-payment for out-of-network services. You may also need to pay the difference between our payment and the actual charges for services received.
As in an HMO plan, the patient must select a primary care physician (PCP). However, the covered person may choose at the time he or she seeks medical services whether to use a network or non-network provider. Network providers accept pre-negotiated fees from insurance carriers as payment for various services, with patient responsibilities for a co-payment at the time the service is provided. If the patient uses a non-network provider, he or she must satisfy the deductible and coinsurance requirements. If the patient chooses a non-network provider, he or she will assume a larger portion of the cost.
an HMO plan that also incorporates an indemnity plan option allowing members to obtain medical care from providers outside of the HMO network at a reduced benefit and at greater out-of-pocket expense
An option which allows an enrollee to go outside the network to receive treatment by paying a greater cost of the treatment.
A type of health benefit plan that allows Members to go outside the Network for non-Emergency Care, but may result in a lower level of Benefits being paid by the Health Benefit Plan.
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do.
refers to a type of medical plan where you have an HMO type primary care physician but still may recieve benefits if you do not obtain prior referral from your PCP.
An agreement with the insurance provider that allows freedom of choice for the employee. The employee may select medical care from an in-network group of physicians or elect to go to any licensed physician (out-of-network). Benefits as well as deductibles and co-pays vary between these two options.
A product offered by an HMO or FFS plan that has features of both. In an HMO, the POS product lets you use providers who are not part of the HMO network. However, there is a greater cost associated with choosing these non-network providers. You usually pay deductibles and coinsurances that are substantially higher than the payments when you use a plan provider. You will also need to file a claim for reimbursement, like in an FFS plan. The HMO plan wants you to use its network of providers, but recognizes that sometimes enrollees want to choose their own provider. In an FFS plan, the plan's regular benefits include deductibles and coinsurance. But in some locations, the plan has set up a POS network of providers similar to what you would find in an HMO. The plan encourages you to use these providers, usually by waiving the deductibles and applying a copayment that is smaller than the normal coinsurance. Generally, there is no paperwork when you use a network provider.
Generic name for programs in which the subscriber can choose the coverage he or she wishes to receive at the time of treatment rather than on an annual basis. Coverage is determined by the network in which the general dentist or specialist selected by the subscriber participates.
A health plan which offers benefits under both a traditional indemnity plan, and an HMO, or HMO-like plan. At the "point in time" services are rendered, the patient elects which set of benefits will be utilized by choosing to receive services from an in-network or out-of-network health care provider.
Plan A health plan that offers its members the option of receiving services from participating or non-participating providers. Generally coverage is reduced for services by non participating providers
An insurance model which determines coverage by where care is provided at the time of delivery, rather than by enrollment. POS plans allow enrollees to choose between a network and out-of-network providers. Network or contracted providers are paid on a pre-paid, contractual basis and non-network providers are paid on a fee-for-service basis. Enrollees are given the option of choosing non-network physicians at the cost of higher copayments or deductibles.
A primary care physician acts as a gate keeper to further medical care. The member pays fewer out-of-pocket expenses than with a contracted physician and has the option to go outside of the network at an increased cost.
A healthcare plan that encourages the use of participating providers but does not require it. A POS plan gives the member the option of seeing a provider outside the network but the plan pays a reduced rate and the member will have more out-of-pocket expenses.
arrangements in which patients with a managed care dental plan have the option of seeking treatment from an "out-of-network" provider. The reimbursement for the patient is usually based on a low table of allowances, with significantly reduced benefits than if the patient had selected an "in-network" provider.
This network allows providers access to recipient eligibility, share of cost clearance, and medi-reservations. This system can be access through AEVS or a POS device
A managed care plan in which the members choose providers at the point of service — in or out of network — with copayment or deductibles determined by their choice.
A "tiered" health plan under which your coverage level is determined by where you receive care. You pay the least for care coordinated by your primary care doctor, a higher amount if you see a specialist in your network without a referral and even a higher cost if you go to a doctor outside the network.
A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), in which individuals decide whether to go to a network provider and pay a flat dollar copayment (say $10 for a docto r's visit), or to an out-of-network provider and pay a deductible and/or a coinsurance charge.
A product offered by an HMO or FFS plan that gives you the choice of using a selected network of providers, like an HMO, or using non-network providers at an additional cost. If you dont use the network, you must pay substantial deductibles, coinsurance, and copayments.
"The POS plan is a hybrid HMO plan. With a POS plan, participants can elect whether to receive treatment within the plan's managed HMO network, or go outside the newtwork to receive benefits. Simply put, a POS plan is an HMO plan with out-of-network benefits."
The DeltaCare point of service program combines prepaid and fee-for-service benefits. As with a prepaid dental plan, you enroll with a network dentist and receive treatment from that dentist. However, you are free to choose an out-of-network dentist at any time, with benefits paid on a fee-for-service basis.
An option provided by some HMOs that allows members to go outside the plan's physician and hospital network for care, but requires that they pay higher costs for sharing than they would for network providers.
An individual enrolled in TRICARE Prime may select a provider who is not within the network. However, if authorization is not obtained prior to using the non- network provider, the patient must pay 50 percent of the medical bill plus a deductible of $300/individual or $600/family.
A type of managed care plan in which members may obtain services from providers within the plan's network or go outside of the network for treatment. Members typically pay a portion of the cost of their care when they seek treatment outside of the network.
A Managed Care health plan that encourages its members to seek care from certain providers by offering them more reimbursement. Care sought outside the network, however, is still covered just at a lower reimbursement level. Some plans include a POS policy into an already existing HMO health plan.
POS plans are similar to HMO plans. However, POS members have higher out-of-pocket (co-insurance) payments if they choose to directly seek specialists without referrals from their Primary Care Physicians.
POS is a category of healthcare plans in which carriers negotiate agreements with a network of participating physicians to provide healthcare at a reasonable co-payment to participants.
A type of plan that requires members to choose a primary care physician but also allows them to visit out-of-network providers with or without a referral
an option that a health insurance issuer offers to enrollees health insurance coverage which provides for coverage of services only if such services are furnished through health professionals and providers who are members of a network of health professionals and providers who have entered into a contract with the issuer to provide such services, the issuer shall also offer to such enrollees (at the time of enrollment) the option of health insurance coverage which provides for coverage of such services which are not furnished through health professionals and providers who are members of such a network.
A health plan that allows the patient to choose the type of payment method (traditional, PPO or HMO) at the time service is received.