In the United States, health care services are typically provided through either a fee-for-service (FFS) plan or a managed care plan. FFS plans allow individuals to go to any provider or hospital that accepts their insurance and Medicaid or Medicare will pay for each service provided. On the other hand, managed care plans have contracts with providers and hospitals to provide care to their members. When it comes to managed care plans, there are four main types that are offered in New York State.
These include Health Maintenance Organizations (HMOs), Point-of-Service (POS) plans, Preferred Provider Organizations (PPOs), and Specialized Plans. Each of these plans has its own set of rules and regulations that must be followed in order to access health care.
Health Maintenance Organizations (HMOs)HMOs are the most popular type of managed care plan. Members must use network providers and cannot receive coverage outside the network, except in case of emergency or after prior authorization. When enrolling in an HMO, members must choose a primary care doctor within a certain time frame or the plan will choose one for them.
Referrals from primary care doctors may be required to see a specialist, and enrolled individuals may request a permanent referral if they need to see the specialist for a specific period of time. Additionally, members must obtain prior authorization or approval from their plan before receiving certain services.
Point-of-Service (POS) PlansPOS plans are a combination of HMOs and PPOs. They allow members to receive coverage both inside and outside the network, but they may have higher out-of-pocket costs for services received outside the network. POS plans also require members to choose a primary care doctor and obtain referrals from them in order to see specialists.
Preferred Provider Organizations (PPOs)PPOs are similar to POS plans in that they allow members to receive coverage both inside and outside the network.
However, they do not require members to choose a primary care doctor or obtain referrals from them in order to see specialists. Additionally, PPOs typically have lower out-of-pocket costs for services received outside the network.
Specialized PlansSpecialized plans are overseen by the Department of Managed Health Care (DMHC) and only cover certain types of care. These include dental and vision care plans, mental or behavioral health plans, and chiropractic plans. HMOs often use these plans to provide specialized care to their members.
When selecting a managed care plan, it is important to consider all of your options and understand the rules and regulations associated with each type of plan. The HMO report card can help you compare the quality of care for HMOs and medical groups in California. Additionally, this website may not display all the data on the qualified health plans offered in your state through the Health Insurance Marketplace website. To see all available data on qualified health plan options in your state, visit the Health Insurance Marketplace website at HealthCare.