PPO? HMO? Point-of-service? HDHP? What does it all mean?

PPO? HMO? Point-of-service? HDHP? What does it all mean?

December 6, 2017
When signing up for health insurance, a lot of us are familiar with the most common types of plans: preferred provider organizations (PPOs), high-deductible health plans (HDHPs), and health maintenance organizations (HMOs).

But HealthSelect of TexasSM is a point-of-service plan, which many new employees have never encountered before. Yet it is the type of plan chosen by most Texas Employees Group Benefits Program (GBP) members.

The HealthSelect of Texas (in state) plan is a statewide point-of-service plan. A point-of-service plan provides both in-network and out-of-network benefits, but requires the designation of a primary care physician (PCP) and referrals to see specialists. In other words, your PCP should be your primary point of service for getting the care you need. Your PCP is responsible for helping direct you to the appropriate specialists for treatment and obtaining referrals for you to see those specialists. HealthSelect of Texas participants pay less out of pocket if they designate an in-network PCP and get referrals from that PCP if they need to see a specialist, such as a dermatologist or cardiologist. Using a PCP to help decide the most appropriate care helps keep plan costs in check while ensuring members get the care they need.

The Consumer Directed HealthSelectSM  plan is a high-deductible health plan (HDHP) with a health savings account (HSA) and PPO network. This plan is available to people not enrolled in Medicare. The PPO network means that participants have both in-network and out-of-network benefits, but don’t have to designate a PCP or get referrals to see specialists. However, there is a high deductible that must be met each calendar year before the plan will begin to pay for any covered health services (other than preventive care) and prescription drugs. To help offset the cost of the high deductible, the State of Texas contributes funds to a HSA, which can be used to pay for qualified medical expenses.

The HealthSelect Out-of-State plan is a PPO that provides coverage outside Texas. This plan is available only to active employees, retirees not enrolled in Medicare and their eligible dependents living or working outside Texas. As a PPO, this plan offers both in-network and out-of-network benefits, but does not require a PCP or referrals to see specialists.

HMOs are another option available to members living or working in certain Texas counties. Each HMO provides benefits only for doctors, hospitals and other providers that are in a regional network, with the exception of emergency care. The networks are much smaller than the HealthSelect networks. Referrals to see specialists are not required by two of the HMO plans. One HMO, Community First Health Plans, does require participants to designate a PCP and requires referrals for certain specialists.

It’s very important to remember that all HMOs require participants to remain within the network when receiving medical care, or the plan will not pay anything except for emergency care.
 

  PCP designation required? Referrals to specialists required? Out-of-network benefits available?

At-a-Glance Comparison of Health Plan Types

HealthSelect of Texas 
(In Area) Plan
 
(Point-of-service plan)
Yes Yes, for most specialists Yes
Consumer Directed HealthSelect
(HDHP PPO with an HSA)
No No Yes
Community First Health Plans
(HMO)
San Antonio area
Yes Only for certain specialists No, except for emergency care
KelseyCare powered by Community Health Choice
(HMO)
 Houston area
No No No, except for emergency care
Scott & White Health Plan
(HMO)
Central Texas area
No No No, except for emergency care