HMO vs PPO

Obtain a referral from the primary care physician (gatekeeper) before seeing the out-of-network specialist — A POS plan is a managed care hybrid: like an HMO it requires the member to select a primary care physician who acts as a gatekeeper, and like a PPO it allows care outside the network. The tradeoff is that using an out-of-network specialist ordinarily requires a referral from the primary care physician, and out-of-network care carries higher cost-sharing. Because the gatekeeper-referral mechanism is preserved, the member must obtain that referral before the out-of-network visit.

National insurance concept

Lets the member see any Medicare-eligible provider who agrees to accept the plan's payment terms and conditions — A PFFS plan is a type of Medicare Advantage plan that sets its own payment amounts for services. Members may receive care from any Medicare-eligible provider willing to accept the plan's terms; if a provider agrees to treat the member, it is paid according to the plan's fee schedule. PFFS plans do not necessarily require a gatekeeper or network, though some use networks to control costs. The any-provider-willing-to-accept-plan-terms feature distinguishes PFFS from HMO-style MA plans. The defining feature of a PFFS plan is that it sets its own payment amounts and terms for each service, and any Medicare-eligible provider who agrees to treat the member under those terms can be used. If the provider does not accept the plan's conditions, the member may be responsible for the full charge, which is why members should verify acceptance in advance.

National insurance concept