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An HMO (Health Maintenance Organization) is the most restrictive of all managed care programs. An HMO normally provides a very high level of medical services through a network of Primary Care Physicians and referral specialists. Office visit co-payments are generally $5 or $10, however all treatments, other than emergencies, must be provided by/or as a referral from a network Primary Care Physician. Otherwise, a member will not be covered.
An Enhanced Access HMO operates the same as an HMO with one main difference. A member can choose to self refer to an in-network specialist and still have coverage under the program.
A POS program offers less restrictive access to medical services than either an HMO or an Enhanced Access HMO. A POS program combines the managed care features of an HMO with the freedom of choice of a traditional health care plan. At the "point of service"-that is, the point when medical care is needed-the member decides whether to receive in-network or out-of-network care. As with the HMO, in-network services require that a member first contact their Primary Care Physician and then be referred to a network specialist by that same Primary Care Physician. If a referral is not obtained or if you choose to go out-of- network, benefits will be paid at a lower level.
A PPO is the least restrictive of all managed care programs. Members can enjoy benefits for eligible health services received from virtually any doctor or hospital they choose. If they choose a network provider, their benefits will be paid at a higher level than if they choose an out-of-network provider.