How do HMO, HMO-POS and PPO Plans Work?

How do HMO, HMO-POS and PPO Plans Work?

Sep 23 2021

If you’re considering a Medicare Advantage plan, you’ll want to look at the plan’s network. That’s where HMO, HMO-POS and PPO come in.

When it comes to health insurance coverage, you should never find yourself bogged down by all the terms and acronyms that can be associated with it. Here are some of the more common insurance plan terms you may come across and how they may differ from their counterparts.

HMO plans

A Health Maintenance Organization (HMO) plan has a contract with a limited number of doctors, hospitals and other health care providers, usually in a designated part of the state. As long as you get care from these network providers, you’re covered under the specifics of your plan. If you get care from outside of the network, you’ll have to pay out-of-pocket for all costs. Additionally, you’ll need to consider the following factors:

  • Choosing a primary care physician (PCP) to coordinate all your care.
  • Setting up referrals to see specialists.
  • Coverage options outside your plan’s network

Narrow network” is another commonly used term under the branch of HMOs. Similar to regular HMOs, these plans are usually part of a very limited network of providers, often around a specific geography or hospital system. These plans often offer lower costs when seeking healthcare, but, as the name may suggest, the choice of providers in the network can be narrow.

POS plans

An HMO Point of Service (HMO-POS) plan allows you to go outside the network for care; however you may have to pay more when using these providers. Some other factors include:

  • Choosing a primary care physician (PCP) to coordinate all your care.
  • Getting a referral to see a specialist.
  • Obtaining prior authorization to receive certain services.
  • Financing deductibles surrounding out-of-network benefits.

PPO plans

A Preferred Provider Organization (PPO) plan means you won’t have to get referrals for care. This type of plan allows you to see doctors inside or outside of your plan’s network, however you pay less if you use services that are in network. Additionally, with a PPO you expect:

  • The ability to see a specialist without a referral (although you are still in charge of making your own appointments).
  • An in-network deductible or combined in- and out-of-network deductible.

By now, you hopefully have a better understanding of what each of these plans entail, but how do they play into the actual care you’re receiving? Let’s address some of those questions.

ThinkHealth healthcare 101 monthyl cost of Medicare

Are my doctors in the plan’s network?

If your plan has a network, it includes doctors, hospitals and other health care providers that have a contract with your insurance company to provide services to you. As was indicated in the descriptions of specific plans, you’ll have lower costs for services if you get in-network care. Likewise, if you get care from an out-of-network health care provider, you may pay more. In some cases, such as with an HMO, you may be responsible for the entire cost of care you get outside of the network. Making sure your doctor is part of your plan’s network and accepts your Medicare coverage can save you a lot of money. You can find doctors in the Priority Health Medicare network by going to and using the Find a Doctor tool.

What will my yearly deductible amounts be?

This is contingent upon the specifics of your plan. Make sure you know what you’ll have to pay out-of-pocket before your health plan begins to pay. Look deeper than your monthly premium. Sometimes when a plan’s premium is low, you’ll pay more out of your own pocket in deductibles and copayments. It’s possible that you’ll save more by paying a slightly higher premium for a plan with a lower deductible.

What will I pay for doctor visits?

It depends. What you’ll pay is based on the plan you choose. Pay close attention to your copayments for doctor visits. Copayments to a see a specialist are typically more.

Understanding the ins and outs of health insurance can be a roller coaster, but having the right knowledge and expertise can keep you strapped in safely.

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