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Health Care Reform:

Health Insurance & Affordable Care Act

4 Types of Health Plans: How They Compare

Health Maintenance Organization (HMO) continued...

What doctors you can see. Any in your HMO's network. If you see a doctor who is not in the network, you'll have to pay the full bill yourself. Emergency services at an out-of-network hospital must be covered at in-network rates, but non-participating can doctors who treat you in the hospital can bill you.

What you pay:

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: Your plan may require you to pay the amount of a deductible before it covers care beyond preventive services.
  • Copays and/or co-insurance for each type of care.

Paperwork involved. No claim forms.

Preferred Provider Organization (PPO)

With a PPO, you may have:


  • A moderate amount of freedom to choose your health care providers -- more than an HMO. You do not have to get a referral from a primary care doctor to see a specialist.
  • Higher out-of-pocket costs if you see out-of-network doctors.
  • More paperwork than with other plans if you see out-of-network providers.

What doctors you can see. Any in the PPO's network. You can see out-of-network doctors, but you'll pay more.

What you pay:

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: Some PPOs may have a deductible. You will likely have to pay a higher deductible if you see an out-of-network doctor.
  • Copay or coinsurance: A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a percent of the charges for care, for example 20%.
  • Other costs: If your doctor charges more than others in the area do, you may have to pay the balance after your insurance pays its share.

Paperwork involved. There's little to no paperwork with a PPO if you see an in-network doctor. If you use an out-of-network provider, you'll have to pay the provider. Then you have to file a claim to get the PPO plan to pay you back.

Point-of-Service Plan (POS)

A POS plan blends features of an HMO with a PPO. With POS plan, you may have:

  • More freedom to choose your health care providers than you would in an HMO
  • A moderate amount of paperwork if you see out-of-network providers
  • A primary care doctor who coordinates your care and who refers you to specialists

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