Types of Managed Care Insurance

In the past, most people had a type of health insurance that would allow them to see any doctor or use any hospital. While these plans still exist in the form of commercial or traditional insurance, a majority of people are encouraged or required by their employers to purchase a more restrictive type of health plan such as an HMO or PPO/PPA.

Health Maintenance Organizations (HMO)
Those who belong to an HMO are required to choose a primary care physician (PCP) who coordinates all aspects of care. Because HMO rules may differ, you should call your health plan with any specific questions regarding the treatment you seek. To help in that process, the following general guidelines or characteristics are used by most HMO companies:
• If you need a specialist or need to be hospitalized, your primary care physician will refer you to a specialist or hospital that is in the plan's network.
• If you want to use a doctor or hospital that is not in the plan's provider network, you may need to get approval from your primary care physician or from the plan. If you don't get approval, the plan may not cover your health care expenses.
• If you have an emergency, your plan will cover your care wherever you go as long as you follow the plan's guidelines about what to do in the case of an emergency.
• Many HMOs also now have flexible rules regarding the use of OB/GYN physicians for women's annual check-ups. Be sure to contact your HMO for your specific coverage.

A Point of Service Option is typically offered by an HMO to give subscribers more flexibility than the traditional HMO plan. An enrollee in a POS has the option of using their coverage either as an HMO or Preferred Provider Organization (PPO see below).
• If you use the plan like an HMO and your primary care physician coordinates all your care, your health care expenses (excluding co-pays and/or deductibles) are covered in full.
• If you self-refer or if you want to use a doctor or hospital that is not in the plan's provider network, you can do so but will be required to meet the higher meet deductible and/or co-insurance payments.

Preferred Provider Organizations or Preferred Provider Arrangements (PPOs or PPAs)
These types of plans usually cover all medical expenses if you use a physician and/or hospital in the plan's provider network (a provider preferred by the plan); however, you do have the option of using any provider you want. If you choose to use a provider outside of your plan's network, there is a deductible and/or co-insurance payment required. PPOs or PPAs do not require that a primary care physician coordinate your care. Under a PPO or PPA arrangement, you can self-refer.