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HMO (Health Maintenance Organization)

An HMO is an organization that provides its members with comprehensive healthcare services through an established group of network providers including doctors, hospitals, pharmacies, labs, etc. HMO's are proactive in their approach to promote wellness and preventative medicine by encouraging physicals and by offering discounts to services such as gyms and other wellness facilities. In theory, early detection and prevention saves the carrier money before medical conditions worsen and costs escalate. Generally a primary care physician (PCP) is selected to oversee the medical management of the member and act as the 'gatekeeper'. The PCP may be the internist, pediatrician, or even a woman's gynecologist. One of their roles as the gatekeeper is to authorize the services beyond their scope of their expertise by way of a referral. The referral would often be required for specialist visits, scheduled surgeries, diagnostic tests, and hospitalizations. However 'open access' HMO's are becoming very popular and now allow the participants to self refer. With an HMO, your choice of doctors, hospitals, and other providers is restricted to a network except in the case of an emergency. In most cases, preauthorization by the carrier it is still required for treatment outside of the network. The network of providers is paid by the carrier on a predetermined basis for the services rendered. The cost to the member is usually limited to a small co-payment which represents a percentage of the overall medical cost. Due to the increasing costs of healthcare, cost sharing plans are becoming more common passing more of the financial burden to the member by way of in-network deductibles and/or coinsurance.

POS (Point-of-Service)
 

POS is a type of managed care plan that offers in-network benefits as well as out of network coverage. The in-network coverage is very similar to the standard HMO and the plan designs can be customized in the same way. Usually the only cost to the member is a small co-payment. The out-of-network coverage's are similar to the traditional indemnity plans whereby the member is indemnified for the services rendered as opposed to a pre-arranged or contracted fee arrangement with the provider in an established network. Point of Service plans allow the member to point to the service they desire.

The out-of-network portion is generally subject to an annual deductible before any reimbursement to the user. Once the deductible is reached, the member is usually responsible for their share of the coinsurance up to a stop-loss level. The coinsurance percentage can be as high as 50% and the stop-loss level, which is the threshold as to when the coinsurance no longer applies, can be as high as $20,000 or more. This coinsurance provision normally applies to each and every procedure as well as for each and every family member. Provider payments are subject to a 'usual, customary, and reasonable', or UCR rate level which is based on the HIAA rates schedule. This schedule generally represents the amount the insurance carrier will pay for a procedure in a given region. The UCR level is a percentile that depicts a percentage of providers that charge within the schedule. This percentile can be increased to encompass a greater number of providers, thus allowing a higher amount of covered charges.

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