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Health Maintenance Organization (HMO)
An HMO plan generally provides comprehensive coverage by requiring members to receive services from a contracted health care provider.
As an HMO member, you must choose a Primary Care Physician (PCP) from one of the primary care specialties, such as Family Practice, Internal Medicine, or Pediatrics. Your PCP will coordinate your health care and refer you to specialists if medically necessary.
The HMO will prepay the Participating Medical Group (PMG) for your membership and health care each month. You may be responsible for copays, deductibles and non-covered services.
Usually, referrals are made primarily within the medical group. However, a new not-for-profit HMO, Western Health Advantage, allows you to seek any medically necessary specialty care from any specialist who practices within its network of four medical groups: Mercy Medical Group/Mercy, Woodland Healthcare, UC Davis and the North Bay Healthcare System. This feature gives members much more freedom of choice when specialty care is really needed.
Point of Service Plans (POS)
A POS plan allows the member to choose to receive a service from their Participating Medical Group (PMG) or from a non-participating provider, with two different corresponding benefit levels. HMOs offer some POS plans in addition to or in place of their regular HMO plans, with limited or expanded service levels. Or, a Preferred Provider Organization (see below) may offer POS options as an additional benefit. Many versions of this type of benefit exist and some employers offer their employees the option of choosing from several of these plans.
Medicare Risk HMO Plans
Anyone who is eligible for Medicare may enroll in a Medicare HMO plan. These plans may offer the member more services than traditional Medicare, including periodic health evaluations, pharmacy benefits and hearing aids.
Preferred Provider Organization (PPO)
Insurance companies contract with medical groups and hospitals to provide medical services to PPO members for discounted rates. If you choose a PPO, you select a PCP from a preferred provider network in order to receive your benefits at the lowest cost. If you go "out of network," your fees (deductibles and copayments) may be much higher.
Indemnity Plans/"Fee for Service"
These plans allow you to choose your providers from any group or health care facility. You are responsible for a percentage of your health care costs, which may take the form of deductibles or reimbursements. One disadvantage of this type of traditional insurance is that it doesn't cover many preventive medicines and procedures, such as routine physicals.