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How HMOs and POS Plans Work?

Health maintenance organizations (HMO) deliver health care to members using provider networks, which are the groups of doctors, hospitals and other health care providers that have agreed to serve members of a particular HMO. Health benefits are covered if the member uses providers that are in-network.

All New York HMOs also offer a point of service (POS) option to individuals that allows members to seek care from providers that are out-of-network. Services provided by out-of-network providers generally cost the member more in out-of-pocket expenses.

The table below highlights some of the important similarities and differences between HMOs and HMO POS options.

Choices Available for Individual Coverage
Under New York State Insurance Law, New Yorkers purchasing health insurance on their own can choose either an HMO plan or an HMO’s POS option at any time during the year. They cannot be denied coverage if they have health problems. However, they may be subject to certain pre-existing condition limitations before coverage begins.

A Word About Premiums
If you want to compare prices of HMOs in your area, current premiums can be found in this online guide.

How Members Get Care
Question to compare HMO POS Option
Can I get services from providers who are out-of-network? No. The HMO pays for all covered services as long as you use in-network providers. If you go out-of-network, you pay the entire cost. Yes. You pay more for out-of-network providers and fewer health services may be covered.
How do I pay for services? There is no deductible. You are charged a copayment (usually between $5 and $25) for a physician office visit.

You usually do not need to fill out claim forms.

If you use an in-network provider, there is no deductible and you are charged a copayment. You do not need to fill out a claim form.

If you use an out-of-network provider, you may pay a deductible and a greater portion of the medical expenses. You may need to fill out a claim form.

Do I need to choose a primary care physician (PCP)? Yes. You are usually required to choose a PCP from a list of in-network doctors. Your PCP takes care of most of your medical needs.

Yes. You usually need to choose a PCP from the list of in-network doctors.

You have the option of using the PCP or going to a doctor who is out-of-network.

Do I need a referral from my PCP to see a specialist? Yes. Before you go to a specialist, you usually need a referral from your PCP. Sometimes. You usually need a referral from your PCP to see an in-network specialist, and to be covered with the maximum benefit with minimum cost to you.

You do not need a referral to see an out-of-network specialist, but you will probably pay more in copayments and deductibles.