What is the Difference Between a PPO, POS and HMO?

How to Choose the best Health Plan Type

It is important to know the difference between a PPO (Preferred Provider Organization), POS (Point of Service) and HMO (Health Maintenance Organization) when hopping for health insurance in Georgia. When comparing the different plan types remember that we are not referring to the healthcare benefits of the policy, but rather which medical providers you are allowed access to with your health plan.

Preferred Provider Organization (PPO)

With a PPO health plan you have access to a network of physicians, outpatient care centers, lab and x-ray facilities and hospitals that have agreed to a reduced fee schedule. When you receive healthcare from an in network provider the billed amount from the provider will be re priced according to the terms with the PPO fee schedule. PPO plans became popular in the 1990's when insurance carriers started offering copayments for services such as office visits without having to first meet a medical deductible.

You also have coverage for out of network providers on a PPO health plan, but there are no discounted fees and the insurance carrier will not always accept the providers full billed amount as an acceptable fee. In Georgia an emergency must be processed as an in network benefit even if the medical care is received from an out of network provider.

Point of Service (POS)

One of the most popular plans in today's Georgia health insurance marketplace is the POS plan. Traditional POS plans were a blend between a PPO plan and an HMO plan. This meant that in order to receive the higher in network level of benefits you needed to select a Primary Care Physician and then they would refer you to a Specialist when necessary.

In Georgia today insurance companies sell what is called an "Open Access" POS plan. This means that you do not need to select a Primary Care Physician but rather you have "open access" to any in network physician. To the consumer there is no difference between a PPO and an Open Access POS plan - both plans allow you direct access to physicians with no referals and services received in network will be reimbursed at a greater benefit level. The difference between these two plans is more in how the medical providers are contacted with the POS network.

Health Maintenance Organization (HMO)

With an HMO health plan you only have access to physicians and hospitals contracted with the HMO provider, unless you need coverage for an emergency. In Georgia the only true HMO provider in the individual health insurance market is Kaiser Permanente. With Kaiser Permanente the physicians you see in their centers are actually employees of Kaiser and only manage the care of Kaiser members. Kaiser does contract with Urgent Care Centers for after hours care..

HMO policies generally provide a high level of coverage for preventive health care services. For instance most Kaiser Permanente plans provide 100% coverage for most x-ray and lab tests. With the Kaiser Permanente Centers you will find that it is very easy to receive care from a physician, have lab work and x-ray tests performed and fill a prescription - all in one place!

If you have a community physician that you want to continue to receive care from then an HMO plan such as Kaiser would not be a good choice since you can only receive care from Kaiser physicians.

PPO, POS or HMO?

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