A health plan that combines features of prepaid and indemnity insurance. Enrollees decide whether to use network or non-network providers at the time care is needed, but are usually charged additional fees for using non-network providers.
Managed care plan which specifies that those patients who go outside of the plan for services may pay more out of pocket expenses. A health insurance benefits program in which subscribers can select between different delivery systems (i.e., HMO, PPO and fee-for-service) when in need of health care services and at the time of accessing the services, rather than making the selection between delivery systems at time of open enrollment at place of employment. Typically, the costs associated with receiving care from the "in network" or approved providers are less than when care is rendered by non-contracting providers. Or the costs are less if provided by approved providers in either the HMO or PPO rather than "out of network" or "out of plan" providers. This is a method of influencing patients to use certain providers without restricting their freedom of choice too severely.
A type of HMO plan that gives patients the opportunity to see providers outside of the network. Patients who use the HMO network of providers pay less than patients who see providers outside the network. The HMO may still require the use of a gatekeeper to authorize in- network services, but no referral is needed for out-of- network services.
A managed care plan that combines features of both prepaid and fee-for-service insurance. Health plan enrollees decide whether to use network or non-network providers at the time care is needed, but usually are subject to reduced coverage and sizable copayments for selecting non-network providers. The increase in POS enrollment represents the area of greatest HMO growth.
A health care delivery system in which insureds are encouraged, but not required, to choose health care providers within the designated provider network. Also known as an open-ended HMO. As in traditional HMOs, the chosen primary care physician acts as a "gatekeeper" when making referrals; plan members may, however, opt to visit non-network providers at their discretion. Subscribers choosing not to use the primary care physician must pay higher deductibles and copays than those using network physicians.
a type of HMO coverage that allows members to see providers outside of the network, usually at a slightly higher co-payment or deductible cost.
a combination of an HMO and a PPO
a little more least restrictive type of managed care
A type of health plan that allows members to go outside the network for non-emergency care, but may result in a lower level of benefits and higher out-of-pocket costs for the member. See health plan product descriptions.
This type of plan is a hybrid between an HMO and a PPO and allows a choice of whether to receive services from a participating or nonparticipating provider.
HMOs whose patients may choose to see outside doctors under certain circumstances, and for higher fees.
Plan that offers a full range of health services through a combination of HMO and PPO features. Members can choose to either use the defined managed care program (with 100 percent coverage) or go out-of-plan for services (with 80 percent coverage).
A health benefit plan allowing the covered person to choose to receive a service from a participating or non-participating provider, with different benefit levels associated with the use of participating providers. Point-of-service can be provide in several ways: 1) an HMO may allow members to obtain limited services from non-participating providers; 2) and HMO may provide non-participating benefits through a supplemental major medical policy; 3) a PPO may be used to provide both participating and non-participating levels of coverage and access; or 4) various combinations of the above may be used.
A plan that combines the cost savings of an HMO plan and the flexibility of a PPO plan. In a POS plan, a primary care doctor acts as a gatekeeper and refers patients to other providers in the plan, but members can refer themselves outside the plan and still get some coverage. If the doctor refers out of the network, the plan pays all or most of the bill. If POS members self-refer to doctors or specialists outside the network, they will have to pay a predetermined amount of co-insurance. Generally, in a POS plan, the level of co-payments and co-insurance will rise based on the choices made by the member.
A health plan in which members can choose non-network providers who are reimbursed by a standard indemnity coverage, with members paying a larger portion of the fee. This plan is sometimes called an open-ended HMO.
( Related information) A modified managed care plan under which members do not have to choose how to receive services until they need them. Members receive coverage at a reduced level if they choose to use a non-network provider.
A point-of-service plan (POS) is a type of managed care plan that is a hybrid of HMO and PPO plans. Like and HMO, participants designate an in-network physician to be their primary care provider. But like a PPO, patients may go outside of the provider network for health care services. When the patients venture out of the network, they'll have to pay most of the cost, unless the primary care provider has made a referral to the out-of-network provider. Then the medical plan will pay.
a type of medical plan that generally provides a higher level of coverage, and may require less paperwork, when the participant coordinates care through his or her primary care physician (PCP).
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.
A health services delivery organization that offers the option to its members to choose to receive a service from participating or a nonparticipating provider. Generally the level of coverage is reduced for services associated with the use of non-participating providers.
An HMO plan, such as MD-Individual Practice Association, Inc. (MD IPA) Preferred, Optimum Choice, Inc. (OCI) Preferred or Optimum Choice of the Carolinas, Inc. (OCCI) Preferred, which allows the member to receive covered health care services with or without a referral from his or her Primary Care Physician (PCP). In a POS plan, when the PCP gives the member referral, the member's covered services will be paid in accordance with the HMO benefits. When the member receives covered health care services without a referral, these services will be paid in accordance with the POS benefits. For M.D. IPA and OCI, POS benefits are underwritten by MAMSI Life and Health Insurance Company (MLH).
These are managed care plans with a variety of copay and deductible options. Members must choose a Personal Care Provider from the provider network. For the highest level of benefits, care needs to be coordinated or provided by the Personal Care Provider. Lesser coverage may be provided if the member self-refers or uses a provider outside the provider network. Members may self-refer for some care and should consult their benefit booklet for specific details.
Health care delivery method offered as an option of an employers indemnity program. Under such a program, employees coordinate their health care needs through a primary care physician.
A type of managed-care coverage that allows members to choose to receive services either from participating providers or from providers outside the HMO's network. In-network care from participating health care providers is more fully covered; for out-of-network care, members pay deductibles and a percentage of the cost of care, much like traditional health insurance coverage.
A plan in which members do not have to choose how to receive services until services are needed. In some plans, for example, members decide whether to use a preferred provider or an outside provider. Although the services of an outside provider are covered, benefits are great if members select a preferred provider.
POS) This HMO option lets members receive treatment from doctors and hospitals outside of the HMO network for a set fee. For more information on POS Plans, click here
A type of managed care plan that combines aspects of health maintenance organizations and preferred provider organizations. POS offers the option of going to a network healthcare provider and paying a flat fee, or to an out-of-network provider and paying a deductible and/or a coinsurance charge. POS Plans are not currently available to Medicare beneficiaries.
A certain managed care plan combing features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs). You may choose whether to go to a network provider and pay a flat dollar amount or to an out-of-network provider and pay a deductible and/or coinsurance charge
A health insurance plan that offers members options for different delivery systems such as HMO, PPO or fee-for-service.
Allows an individual to choose between service from a provider in the plan network or outside of the network, with varying levels of reimbursement.
A point of service plan provides benefits for covered services received from both participating and non-participating providers. When you enroll in a point-of-service plan, you choose a primary care physician (PCP) for yourself and each covered dependent. In order to receive the higher level of benefits under the plan, you must access care through your PCP, except for emergency care or direct access benefits. Your are responsible for a copayment. Care received on a self-referral basis may be subject to a reduced level of benefits than care accessed through your PCP, except for direct access benefits. You are responsible for a deductible and coinsurance percentage for self-referred services.
A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPO's), in which individuals decide whether to go to a network provider and pay a flat dollar co-payment (say $10 for a doctor's visit), or to an out-of-network provider and pay a deductible and/or a coinsurance charge.
A type of managed care plan combining features of health maintenance organizations (HMOs) and preferred provider organizations (PPOs), into a single plan, in which individuals decide at the time of service whether to go to an HMO provider and pay a flat dollar copayment (e.g. $20 per visit), a PPO provider (e.g. 20% coinsurance after a deductible) or to an out-of-network provider at a higher coinsurance cost.
Health insurance policy that allows the employee to choose between in-network and out-of-network care each time medical treatment is needed.
Also known as an open-ended HMO, POS plans encourage, but do not require, members to choose a primary care physician. As in traditional HMOs, the primary care physician acts as a "gatekeeper" when making referrals; plan members may, however, opt to visit non-network providers at their discretion. Subscribers choosing not to use the primary care physician must pay higher deductibles and copays than those using network physicians.