What Are the Different Types of Plans?
Some of the plans fall under the Health Maintenance Organization (HMO) category, which is a plan where you get your care and services from doctors, other health care providers, or hospitals in the plan’s network (except emergency care, out-of-area urgent care, or out-of-area dialysis). In some HMO plans, you may be able to go out-of-network for certain services, but usually at a higher cost. This is called an HMO with a point-of-service (POS) option.
Like most HMOs, you choose a primary care doctor and need a referral to see a specialist. Certain services, like yearly screening mammograms, don’t require a referral.
If your doctor or other health care provider leaves the plan’s network, your plan will notify you. You may choose another doctor in your plan’s network. If you get health care outside the plan’s network, you may have to pay the full cost, so it’s important that you follow the plan’s rules, like getting prior approval for certain services when needed.
The second type is a Preferred Provider Organization (PPO). They have networks of doctors, other health care providers, and hospitals, but you can also use out-of-network providers for covered services, usually for a higher cost. You’re always covered for emergency and urgent care.
Prescription drugs are also covered in most cases. If you want Medicare drug coverage, you must join a PPO plan that offers prescription drug coverage because it’s not always included.
You do not need to choose a primary care doctor or get a referral to see a specialist under a PPO in most cases.