No. The HMO pays for covered services only if you use network providers. In a medical emergency, the HMO will also pay for covered services from a non-network provider. |
Yes, but you usually pay more than if you go to a network provider. |
There is no network. You may get care from any provider. |
You are usually charged a co-payment (usually between $5 and $50) for a doctor’s office visit and most other services. You may or may not have to satisfy a deductible. HMOs may impose a coinsurance for some services. You usually do not need to fill out claim forms. |
If you use a provider who is in the network, you typically 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 the coinsurance specified in your policy (which may range from 10–50%) 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 the coinsurance specified in your policy (which may range from 10–50%) 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.
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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. |
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. |