HMO
What does it stand for? HMO stands for Health Maintenance Organization.
What it is: You must normally choose a primary care physician (or “PCP”) from a local network of health care providers under an HMO plan.
You must see this provider first if you become ill or injured.
If your primary care physician is unable to offer the care you require, they will refer you to a specialist who is also a member of a local network.
Your primary care physician (PCP) acts as your health-care “quarterback,” organizing your treatment and guiding you to the appropriate resources.
Bob, for example, is suffering from back pain.
He goes to his primary care physician for a checkup.
Bob’s PCP decides that seeing a chiropractor is the best course of action.
Bob’s PCP writes a reference for him to see one of the chiropractors in Bob’s network.
HMO plans are often less expensive than other types of insurance.
HMO patients are limited to a network, and they cannot see a specialist without a referral, nor can they obtain coverage for services acquired outside of the network.
Preferred Provider Organization (PPO) is the abbreviation for Preferred Provider Organization.
What it is: A PPO plan normally does not necessitate the use of a primary care physician.
Your plan will feature a network of different health care providers, including both generalists and specialists, and patients will be able to see any of those providers without needing a referral.
Out-of-network care is covered, unlike in an HMO, however it is usually more expensive.
Susan, for example, is suffering from stomach pain and digestive issues.
She has the option of scheduling an appointment with any provider in her network.
She can see any general practitioner in her network if she believes a general practitioner can diagnose and treat her.
Alternatively, if she prefers to see a specialist, she can skip the general practitioner and schedule an appointment with one of the gastroenterologists in the network.
Alternatively, she is free to see a provider outside of her network.
While the visit is still covered, it will be more expensive than seeing a provider who is in your network.
Advantage: PPO members have more flexibility than those with other types of plans since they can go to any provider in the network without needing a referral.
Disadvantage: A PPO plan’s enhanced flexibility usually comes at a higher cost.
While PPO consumers have the option of visiting doctors outside of the network, doing so may result in a reduction in coverage.
POS
What does it stand for?
Points of Sale
What it entails:
A Point of Service plan is a cross between an HMO and a PPO, integrating aspects of both.
In a similar way to how an HMO works, patients choose a primary care physician who makes referrals within the network.
When a POS patient leaves the network, the plan functions more like a PPO, with the patient still being covered but at a higher premium.
Laura, for example, is experiencing joint pain and makes an appointment with her Primary Care Provider.
Laura is referred to a specialist by her PCP after she has been evaluated.
Laura can see that specialist or seek out a specialist outside of her plan’s network on her own.
Advantage: A POS plan offers even more flexibility than other plan types because it allows you to receive care inside or outside of the network.
Access to specialized care, like with an HMO, requires a referral.
A stethoscope and a prescription are required.
EPO
Exclusive Provider Organization is what it stands for.
What it is: An Exclusive Provider Organization, like a POS, combines aspects of HMO and PPO insurance.
Patients in an EPO plan do not need a primary care physician or referrals to see specialists, but they are limited to a network of providers, much like in an HMO.
Greg, for example, has knee difficulties and may require surgery.
He can see any knee specialist he wants without needing a referral, as long as the physician is in his plan’s network.
EPO plans have the advantage of providing access to specialty treatment without the need for referrals.
Because of the network, specialized care may be limited.
PFFS
Private Fee-for-Service is what it stands for.
What is a Private Fee-for-Service Plan? A Private Fee-for-Service Plan is a type of Medicare Advantage plan.
In a PFFS plan, the level of cost-sharing between the beneficiary and the health-care provider is determined by the insurance company providing the plan.
Patients in PFFS plans are not required to see a primary care physician or obtain a referral before seeing a specialist.
A PFFS plan may or may not have a provider network.
Mark, for example, has a sprained ankle and needs medical attention.
He is free to see any health care professional who has agreed to accept Mark’s insurance company’s payment terms.
The lack of a network in many PFFS plans is an advantage.
Patients may still be able to receive care outside of the network under the same payment terms if the health care provider agrees.
Disadvantage: There is no certainty that a health care provider will accept the insurance company’s payment terms for a PFFS.
Family members of all ages are beaming.
SNP
Special Needs Plan is what it stands for.
What is a Special Needs Plan? A Special Needs Plan is a form of Medicare Advantage plan that only accepts patients with particular conditions or health-care needs.
In an SNP, the benefits offered and the list of participating providers are adjusted to meet the beneficiaries’ individual needs.
SNPs usually necessitate the presence of a primary care physician or, at the very least, the presence of a care coordinator who will function in a similar capacity.
For the majority of treatment, most Special Needs Plans require a referral to a specialist.
Anita, for example, suffers from End-Stage Renal Disease, which is one of the diseases covered by SNPs.
Anita can obtain care from a network of clinicians, suppliers, and facilities that specialize in treating End-Stage Renal Disease whether she needs an assessment, therapy, or any other service or product.
Advantage: A Special Needs Plan can give the specialized and tightly targeted care that patients with certain health issues demand.
SNPs may not be available where you reside, which is a disadvantage.
ACO
Accountable Care Organizations is what it stands for.
What is an Accountable Care Organization? An Accountable Care Organization is a collection of health-care professionals who have voluntarily joined together to provide coordinated care to Medicare and Medigap patients.
An ACO’s purpose is to give beneficiaries (especially chronic illness participants) with streamlined care that reduces duplication of effort and improves communication between participating physicians.
Henry, for example, is under the care of an ACO and is suffering from an asthmatic problem.
Henry’s medical team consults with one another to review his previous treatments, testing, and present problems.
The team then devises a strategy for Henry and steers him in the right direction.
Advantages: Because of the coordinated efforts of health care providers who are invested in the cause, ACOs can provide better care quality.
