PCP Referral and Plan Authorization Highlights by Product Type
Health Maintenance Organization (HMO): Health Maintenance Organizations focus on prevention and wellness and tend to be the most structured managed care plan. Patients who have coverage through an HMO are required to select a primary care physician (PCP) affiliated with the plan. The PCP is responsible for coordinating care with specialty providers through the referral process. Physicians generally refer their patients to colleagues within the same provider system. Most services provided outside the primary care setting require a PCP referral. In addition to a referral, certain services such as outpatient surgery or an MRI may require plan authorization from the health plan.
Preferred Provider Organization (PPO): Different from an HMO, patients do not have to select a primary care physician (PCP) to coordinate their care and are allowed to self refer (no referrals required) for specialty services. Also, unlike an HMO, patients may see a provider within the PPO network or obtain services outside the provider network. No referrals are required for specialty care, however certain services such as outpatient surgery or an MRI may still require a plan authorization from the health plan. These requirements vary significantly with PPO type products.
Point of Service (POS): A health plan that offers the patient several options for receiving health care services. The benefit and copays costs will vary depending on the physician and hospitals the patient chooses. Patients with a POS product can choose to either coordinate care through their PCP or self-refer (no referrals required) for specialty care. The least expensive option is using your POS like an HMO, which means that you coordinate your care with your PCP and get a referral prior to seeing a specialist. You may also choose to self-refer for specialty care. This means you do not have to see your PCP before seeing a specialist. These options allow you more choices but can result in higher out-of-pocket costs such as higher copays, deductibles, and/or coinsurance. With either option, certain services such as outpatient surgery or an MRI may still require a plan authorization from the health plan.
