Managed Care Organization (MCO) Plans

Managed care organization (MCO) is a type of health insurance that have contracts with healthcare providers to help members to provide services at low cost. Providers are contracted with health insurance under MCO plans and based on these plans, the cost of the patient's health services is dependent. An individual can select any plan and the flexibility of a plan depends on the cost of the plan. If an individual wants a more flexible plan then it will cost more.

There are 4 types of MCO plans:

1) HMO (Health Maintenance Organization) -

• This plan allows In-network benefits only which means that patients can only take services from providers who contracted with health insurance.
• Out-of-pocket expenses are less since providers are In-network.
• A primary care physician (PCP) visit is required. The patient needs to visit PCP before visiting a specialist.
• A referral is required. When a patient visits PCP a referral is provided to the patient.

2) PPO (Preferred provider organization) -

• This plan allows Out-of-network benefits which means that patients can visit any doctor as per requirement.
• Out-of-pocket expenses are more since providers are Out-of-network.
• A primary care physician (PCP) visit is not required. The patient does not need to visit PCP before visiting a specialist.
• A referral is not required since the patient is not visiting PCP.

3) POS (Point of service) - 

• This plan allows Out-of-network benefits which means that patients can visit any doctor as per requirement.
• Out-of-pocket expenses are more since providers are Out-of-network.
• A primary care physician (PCP) visit is required. The patient needs to visit PCP before visiting a specialist.
• A referral is required. When a patient visits PCP a referral is provided to the patient.

4) EPO (Exclusive provider organization) -

• This plan allows In-network benefits only which means that patients can only take services from providers who contracted with health insurance.
• Out-of-pocket expenses are less since providers are In-network.
• A primary care physician (PCP) visit is not required. The patient does not need to visit PCP before visiting a specialist.
• A referral is not required since the patient is not visiting PCP.