HMO

A Health Maintenance Organization (HMO) is a benefit plan that has one benefit level: in-network; it allows enrolled members, who live in a defined service area, to use participating HMO providers in order to receive benefits. HMO members must have all care authorized by their Primary Care Physician (PCP). There are minimal copayments, but no deductibles and virtually no claim forms. There aren't any out-of-network benefits.

POS

A Point-of-Service (POS) is a benefit plan that has two benefit levels: in-network and out-of-network. In-network benefits provide the maximum benefit to members and provide the same cost and quality controls of the HMO product with minimal co-payments. To maximize in-network benefits, members are required to select a PCP from the insurer's directory of participating providers; the member's PCP will coordinate all of the members' health care needs. Members can choose, at the time services are needed, to seek care from an in-network provider and receive the highest benefit level possible or go out-of-network and receive benefits that are subject to deductibles and coinsurance.

A pre-existing condition is a sickness or injury (whether physical or mental), regardless of cause of the condition, for which medical advice, diagnosis, care of treatment was recommended or received within the six month period prior to the enrollment date. Health insurers can exclude coverage for up to twelve months for pre-existing conditions.

An employee experiencing a significant life status change will be able to change their dependent coverage within the tier level that was selected by the employer. These dependent changes can be made only with the benefit plan and the insurer previously selected by the employee. A change of insurer and benefit plan is only allowed at renewal (open enrollment). The effective coverage date for a Significant Life Status Change is the date of the qualifying event.
Significant life status changes include: marriage; divorce; death; birth; adoption/legal guardianship; or loss of eligibility for health coverage due to termination of employment (except for reasons of gross misconduct) or reduction in work hours below 20 hours per week.
Any significant life changes must be reported on a Healthcare Enrollment/Change Form and sent to the Enterprise Enrollment Processing Center. The Enrollment Form must be received within 30 days of the qualifying event.