What do those three letters mean? To start, HMO stands for Health Maintenance Organization, and the coverage restricts patients to a particular group of physicians called a network. PPO is short for Preferred Provider Organization and allows patients to choose any physician they wish, either inside or outside of their network. HMOs and PPOs are both types of managed care, which is a way for insurers to help control costs
HMO
- Patients in with an HMO must always first see their primary care physician (PCP). If your PCP can’t treat the problem, they will refer you to an in-network specialist.
- An HMO will not pay for your medical care if you see a doctor outside your HMO’s provider network
PPO
- Patients with a PPO plan can see a specialist without a referral from a primary care physician. Under a PPO plan, patients still have a network of providers, but they aren’t restricted to seeing just those physicians. You have the freedom to visit any healthcare provider you wish
POS
- Patients with a POS are provided a network of providers, however, have the choice to see other providers or seek services without prior approval. If you obtain out-of-network treatment without being referred by your physician, you will likely incur most of or all your charges. A POS member must satisfy a deductible, which is applied to out-of-network visits without a referral, along with higher co-pays and coinsurance. In some cases, you may have to pay in full and then submit a claim to your insurer for reimbursement