| There are three general types of health plans. The following chart may help answer some of your questions regarding the major differences in each of the plans. |
| HMO |
POS |
Fee-for-Service |
| Health Maintenance Organization: A health coverage plan that offers its members a network of doctors and other health care providers. |
Point-of-service: A combination of the HMO and the Fee for Service health insurance systems. There is usually a higher co-payment if you use an out-of-network provider. |
A traditional health insurance system under which doctors are paid for each specific service they give to the patient. |
| Can you get covered services from providers who are not in the network? |
| No. The HMO pays for covered services only if you use network providers. |
Yes, but you usually pay more than if you go to a network provider. |
Yes, You may get care from any provider. |
| How do you pay for services? |
You are charged a co-payment (usually between $5 and $25) for a doctor's office visit and most other services. There is no deductible.
You usually do not need to fill out claim forms. |
If you use a provider who is in the network, you pay a co-payment, but no deductible. You do not have to fill out claim forms.
If you use a provider who is not in the network: after you pay a deductible, you pay co-insurance (usually 20-40%) and the insurer pays the rest up to the insurer's allowed amount. If your provider bills more than the allowed amount, you also must pay the difference between the billed and allowed charges (balance billing). You may need to fill out a claim form. |
After you pay a deductible, you pay co-insurance (usually 20-30%) and the insurer pays the rest up to the insurer's allowed amount. If your provider bills more than the allowed amount, you also must pay the difference between the billed and allowed charges (balance billing).
You will need to fill out a claim form. |
| Do you need to choose a Primary Care Provider (PCP)? |
| You usually need to choose a PCP from the network, who takes care of most of your medical needs. |
You usually need to choose a PCP from the network. |
You do not need to choose a PCP. |
| Do you need a referral from your PCP to go to a specialist? |
| you usually need a referral, although in many HMOs some types of specialists may be available without a referral. Some HMO products allow visits to most specialists in the network without a referral. |
Depends. You usually need a referral only if you want to see a specialist and receive in-network benefits. Some POS products allow visits to in-network specialists and provide in-network benefits without a referral.
If you use a provider who is not in the network, you usually do not need a referral, but you will pay more than if you go to in-network providers. |
You do not need a referral to go to a specialist. |
New Jersey Association of Health Plans · 50 West State Street, Suite 1012 · Trenton, NJ 08608 · Phone: (609) 581-8237 · Fax: (609) 278-4496 
