Most Americans who have health insurance through their employer (and many who are self-insured) are enrolled in some type of a managed care plan – either an HMO or PPO. The most common types of managed care plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Less common are point-of-service (POS) plans that combine the features of an HMO and a PPO. All managed care plans contract with doctors, hospitals, clinics, and other health care providers such as pharmacies, labs, x-ray centers, and medical equipment vendors. This group of contracted health care providers is known as the health plan’s “network.” In some types of managed care plans, (HMO’s) you may be required to receive all your health care services from a network provider. In other managed care plans (PPO’s), you may be able to receive care from providers who are not part of the network, but you will pay a larger share of the cost to receive those services.
HMOs require that you select a primary care physician (PCP) who is responsible for managing and coordinating all of your health care. Your PCP will serve as your personal doctor to provide all of your basic healthcare services. For your children, you can select a pediatrician or a family physician to be their PCP. If you need care from a physician specialist in the network or a diagnostic service such as a lab test or x-ray, your primary care physician (PCP) will have to provide you with a referral.