In New York State, you either receive your health care services through fee-for-service (FFS) or a managed care plan. If you are enrolled in FFS Medicaid or Original Medicare, this means you can go to any provider or hospital that accepts your insurance and Medicaid or Medicare will pay for each service provided. Unlike FFS, if you are enrolled in a managed care plan you must follow certain rules to access medical care. Managed care plans have contracts with providers and hospitals to provide care for their members. Below is a general list of the different types of managed care plans offered in New York State. All managed care plan enrollees have the right to file a grievance or an appeal if they believe they have been denied a service they are entitled to.
For more information about additional services covered by your managed care plan, consult your member handbook or contact CHA at 888-614-5400.
Health Maintenance Organization (HMO)
In a Health Maintenance Organization (HMO) plan, enrollees are required to use in-network providers and cannot receive out-of-network coverage, except in an emergency or after prior authorization. Enrollees are required to choose a primary care physician in an HMO within a certain timeframe after enrolling in the plan, or the plan will choose one for you. Referrals may be required from primary care physicians in order to see a specialist, and enrollees can request a standing referral if they need to see the specialist for a specific period of time. Enrollees are also required to get prior authorization or prior approval from their plan before they receive certain services.
If you are enrolled in a Medicaid Managed Care plan, the Essential Plan, or Child Health Plus, you are likely enrolled in an HMO plan.
Exclusive Provider Organization (EPO)
Another type of managed care plan is an Exclusive Provider Organization, or EPO. As with an HMO plan, EPO plans require enrollees to use in-network providers and cannot receive out-of-network coverage, except in an emergency or after prior authorization. However, enrollees are not required to choose a primary care physician, and referrals are generally not required in order to see a specialist. Enrollees are required to get prior authorization or prior approval from their plan before they receive certain services.
Preferred Provider Organization (PPO)
Unlike HMOs and EPOs, Preferred Provider Organizations (PPOs) allow enrollees to use out-of-network providers for any reason, but the plan will typically pay only 70 to 80% of the out-of-network cost of services based on the plan’s “allowed” amount. The enrollee will pay the additional 20 to 30% in the form of co-insurance plus any charge by the out-of-network provider that is above the “allowed” amount. This above amount is called “balance billing” (see the Key Terms section). With a PPO, enrollees are not required to choose a primary care physician, and referrals are not required in order to see a specialist. Enrollees are required to get prior authorization or prior approval from their plan before they receive certain services.
Point of Service Plan (POS)
A Point of Service Plan, or POS, is a hybrid plan with features of both an HMO and a PPO plan. POS plans allow enrollees to use out-of-network providers, but if they do so they must pay much of the cost themselves unless their primary care physician refers them to a specific out-of-network specialist. Enrollees are required to choose a primary care physician within a certain timeframe after enrolling in the plan, but referrals are not required in order to see specialists. Enrollees are required to get prior authorization or prior approval from their plan before they receive certain services.