Insurance Overview (Continued)

 

With a PPO, out-of-pocket costs are usually limited. The plan predetermines your co-pay amount. Plans with higher monthly premiums may provide more coverage with lower deductibles and out-of-pocket costs. If you belong to a PPO you have more freedom to choose which doctors you go to. PPOs have a list of doctors and hospitals that they consider "in network," but you may still receive some coverage if you get treatment out of network. Unlike an HMO, a PPO plan does not require you to choose a primary care physician or get a referral to see a specialist, even one outside of your network.
   
Although you can receive out-of-network care under a PPO plan, it is more expensive to do so. If you go out of network you have to pay a deductible before your insurance company will begin paying. PPO plans limit out-of-network coverage to what they believe is "usual, customary, and reasonable" for the service you receive. You may have to pay the difference between what the PPO considers usual, customary, and reasonable and the amount the healthcare provider actually charges. You have to fill out paperwork every time you need to be reimbursed for a service.
   
POS (Point of Service)

   
A POS plan is a type of managed healthcare that combines features of an HMO and a PPO. It offers maximum freedom of choice because you can mix the types of care you receive. It encourages you to use in-network providers, but doesn't require it. You choose whether to receive treatment within network or out of network right at the time you receive healthcare.
   
Like an HMO, you have to choose a primary care physician within the POS network. Your PCP directs all of your medical care so he or she is your "point of service." If you want to see a specialist within your network, you must receive a referral from your PCP. If your PCP refers you to a specialist outside of your network, your plan will cover most of the cost. There are no deductibles and you usually only have to pay a minimal co-pay when you receive services in network.
   
Like a PPO, you can go out of network with a POS plan. You are free to see any doctor or specialist you choose without getting a referral from your PCP, but it will be more expensive. You have to pay a deductible and a large part of the doctor's charges as a co-pay. POS plans limit out-of-network coverage to what they determine to be "usual, customary, and reasonable" for the service you receive. If the healthcare provider charges more, you have to pay the difference. You may also have to fill out quite a bit of paperwork yourself before you are reimbursed for out-of-network care.

Reviewd by Joy Pape, RN, BSN, CDE, WOCN, CFNC 10/12

 

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Last Modified Date: May 20, 2013

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