Description

Managed Care

In general, managed care plans make arrangements with particular doctors, hospitals and other providers to deliver services. These providers make-up a plan’s “network.”

Fee-for-Service (FFS)
You and the insurer each pay for part of the costs for health care services that you receive.  There is a fee associated with each service provided.

HMO

A health insurer that directly contracts with or employs a network of doctors, hospitals and other types of providers.
Providers generally receive a fixed fee for each health plan member for whom they provide care.

POS

Combines an HMO with the flexibility of an out-of-network option. You can use providers in the plan’s network or go outside of the network.

PPO

Most similar to fee-for-service except has a network. When you use a provider in the network, your costs are lower and more services are covered.

What is your choice of doctors and hospitals?

You agree to get care from providers in the network.

You can use providers that are in- or out-of-network.

When you go out-of-network, you will usually pay more and fewer services are covered.

You can use providers that are in- or out-of-network.
When you go out-of-network, you will usually pay more.

You have an unlimited choice of doctors and hospitals.

How do you get specialty care?

You may need a referral to go to a specialist who is also in the network.

You may need a referral to a network specialist to receive in-network coverage.
You can go to a specialist who is not in the network without a referral.

You do not usually need a referral to go to a specialist; however, certain services may require pre-authorization from your health insurer.

You do not need a referral.

How do you pay for services?
    In network

There is no deductible. You pay a copayment usually between $10 and $25 for a doctor’s office visit and most services.

If you use a provider in the network, there is no deductible, but you pay a copayment.

You pay a portion of the cost, typically 20%-30%, known as coinsurance.
Network providers agree not to charge more than the insurer’s allowable charge.
Some PPOs may charge a copayment instead of coinsurance.
Some PPOs may require members to satisfy an annual deductible before covering services.

Your doctor or hospital sends a bill for services provided. After you pay your deductible, you are responsible for a portion of the costs, typically 20%-30%, known as coinsurance.
Most insurers have a predetermined fee, called an allowable charge, for a service. For example, if your doctor charges $125 for a visit and your insurance only allows $100, you may be responsible for the $25 difference in addition to your deductible and coinsurance.

   Out-of-network

Out-of-network services are typically not covered.

If you use a provider who is not in the network, then you are reimbursed for services as you would be with fee-for-service insurance.

If you use a provider who is not in the network, then you are reimbursed for services as you would be with fee-for-service insurance.