HMO Plans Overview:

With an HMO plan, in most cases you must see a provider, or primary care physician (PCP), within your network. Your primary caregiver acts as your gatekeeper of sorts, referring you to others within your network. (If you want to see a specialist, you may need to get a referral from your doctor.) Because this defined network can help control costs, premiums tend to be lower with an HMO, which is also commonly paired with a low (or no) deductible. Here are more details about HMO plans:

Relationship to providers/doctors

In HMOs, providers or doctors either work for the HMO or contract for set rates as opposed to being paid per service they perform.

In-network versus out-of-network care

In most cases, if you belong to an HMO, you must use in-network care, meaning care from those health care facilities or doctors that are in the HMO’s network. Out-of-network care is allowed in emergency cases only.

Referrals and Primary Care Physicians (PCPs)

In HMOs, you will likely have to choose a PCP. This PCP is your main health care contact. Your care is often coordinated through them. You may even need to get a referral from them to see a specialist.

Preapprovals for medical services

You may need to get advanced approval before having certain medical services performed, but in an HMO, in many cases that preapproval will be handled through your PCP, if you have one.

POS Plans Overview:

A POS plan is a combination of an HMO and PPO. Members need a referral to see a specialist and will have some coverage for out-of-network care (often with a higher copay). Here are more details about POS plans:

Relationship to providers/doctors

In a POS network, like with a PPO, there are negotiated rates on medical services in the network for POS health plan insureds.

In-network versus out-of-network care

You must generally stay in-network for services, but may be authorized for out-of-network services in limited cases. However, just like with a PPO, if you do go out-of-network, your benefits and coverage may be less.

Referrals and Primary Care Physicians (PCPs)

As is the case in an HMO, in a POS you often must have a PCP coordinating your health care. Also, you often need referrals from your PCP to see a specialist, or in the case of POS, to go out-of-network for care.

Preapprovals for medical services

A POS is like an HMO in that some health care services will need preapproval. However, your PCP, if you have one, will often take care of that preapproval for you.