Learn about the Types of Managed Care Health Insurance Plans in Virginia

Health Maintenance Organizations (HMO) are the most familiar form of managed care plans. HMO members pay a fixed dollar amount, usually monthly, which gives them access to a wide range of healthcare services. Members pay a predetermined fee or co-payment for each hospital visit, doctor, or emergency room visit, and for prescription drugs, rather than paying the provider in full and obtaining a portion of the reimbursement later. HMOs generally eliminate the need to file claims.

When you enroll in an HMO, you must select a primary care physician (PCP) to manage your healthcare. With a few exceptions, you must first consult with your PCP for healthcare needs. If necessary, your PCP may refer you to an HMO approved specialist. If you do not get approval from your PCP before you seek medical care, you may be responsible for payment for those services.

As HMO carriers continue to seek ways to contain costs while responding to consumers' changing needs for healthcare services and benefits, HMO plan designs also continue to change. Some of the newer plan designs may offer more services without PCP approval, and/or different forms of cost-sharing, including the requirement for an enrollee to pay an annual deductible for certain services rather than a copayment for each specific service.

Preferred Provider Organizations (PPO) plans issued by an insurance company are plans that provide higher reimbursement if you go to a "preferred" or "participating" provider that provides services to health plan members for discounted fees. Insured individuals choose who will provide their health services, but they pay less in out-of-pocket expenses with a preferred (participating) provider than with a non- preferred (non-participating) provider.

Point of Service (POS) Plans offer HMO enrollees the option of receiving services outside the HMO's network. Inside the network, the plan operates like an HMO. POS plans offer lower out-of-pocket costs to the enrollee using the services of providers inside the network. In a POS plan, insured members choose, at the point of service, whether to receive care from a healthcare provider within the plan's network or to go out of the network for services. POS plans offer less coverage for health care expenses provided outside the network than for expenses incurred within the network. Visits outside the network normally require the payment of deductibles and coinsurance.