Open Enrollment Insurance Information

What is the difference between a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO) and Point of Service (POS) managed care plan?

HMO Plans

  • Require you to select a primary care physician (PCP) and see providers within the network if you want your care paid by insurance
  • Usually require a small co-pay for each visit but do not require a deductible or other payment for authorized/covered services
  • Some services require pre-certification or prior authorization, some do not

PPO Plans

  • Don't require that you select a specific PCP and you are able to see providers out-of-network
  • Costs will be higher if you choose an out-of-network provider instead of an in-network provider
  • PPOs have a deductible that you must meet before insurance will pay for your benefits
  • These plans generally pay only a percentage of the charges (often an 80/20 percent split); the co-insurance, or balance due (the 20 percent) is your responsibility
  • Some services may require pre-certification or prior authorization, some may not

POS Plans

  • Tier one is the HMO portion and acts like the HMOs described above
  • Tier two is the PPO portion and acts like the PPOs described above
  • Tier three (if available) usually acts as an out-of-network option that covers services at a much lower rate than the PPO option above; This may be useful if you are out of state or out of the country
  • The value of a POS plan is that at the point of service (each time you require medical services), you can decide if you want to use your Tier 1, 2 or 3 level benefit
  • Premiums may be higher because you are paying for the added levels of benefits

Did You Know?

  • With most plans, current employees can switch to a UC San Diego Health System PCP at any time during the year.
  • Our PCPs accept virtually all major HMOs, PPOs and MediCare
  • You may make appointments with most of our specialists without having to go through the insurance authorization process
  • Since there are so many versions of each health plan available to you, please call the member services phone number on your insurance card if you want to know if a specific test/procedure is a covered benefit

Glossary of Insurance Terms

Physician Referral Service

Our knowledgeable, experienced staff can provide:

  • Guidance in choosing a primary care or specialty physician
  • Information about insurance plans accepted by UC San Diego Health System
  • Enrollment in classes and seminars
  • Information about services, programs and Centers of Excellence

Call toll free Monday – Friday, 8 a.m. to 5 p.m., 800-926-8273