Health Insurance Blog

What’s The Difference Between HMO, PPO, POS, or EPO plans?

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When selecting a health insurance plan, there’s a lot of options to consider.

Here’s one of them: deciding what type of network will work best for you.

If you are looking for health insurance options on the Marketplace (also known as Obamacare or Affordable Care Act plans, which have a special enrollment period right now ending August 15th), don’t just focus on the monthly premium costs. The marketplace mostly provides HMO & EPO options, while individual plans such as Short Term Medical and Off-Exchange ACA plans also provide PPO and POS network options.

Of course, costs are important, but there are other factors to consider when choosing a plan. 

“What in the world do all those acronyms mean & and how do I identify which is best for me?” 

First, let’s look at those crazy acronyms:

HMO – Health Maintenance Organization: A primary care provider and referrals are required. Does not provide services out of the network.

PPO – Preferred Provider Organization: No referrals or PCP required, provides a larger network and out of network access. 

POS – Point of Service – Like an HMO plan but with out-of-network coverage.

EPO – Exclusive Provider Organization: Like a PPO but with a more limited network and no out of network access.

Now for the details

This is a group of healthcare providers such as doctors, pharmacies, therapists and healthcare facilities, etc., who accept your health insurance coverage and have contracted with the health insurance carrier. Network providers have agreed to reduce their rates for the members of that network. A good rule of thumb is, the larger the provider network the more choices you will have when it comes to choosing a primary care provider or a specialist. 

Often when you call to make an appointment with a specialist they will ask “Do you have a referral?”. Certain types of networks may require your primary care physician (PCP) to provide you with a referral.  In this case, your PCP is called the “gatekeeper” and determines if you need to see a specialist. You are free to pick up the phone and make an appointment with anyone you’d like but if your plan network requires a referral and you go on your own, the health insurance will not cover that visit. With your PCP’s approval, you can expect to see lower costs.

This is a question you have to answer for yourself but here are a few pointers you can keep in mind:  Before you start this endeavor, make a note of your needs and wants regarding your provider network and benefits. Think of any doctors or hospitals you want to make sure you can see and keep that information at hand while you shop. Check the networks you’re considering for doctors, hospitals, and pharmacies near to you before making any decisions, especially if easy access to care is important.

  • If your doctor’s already in-network, or you don’t have any specific providers you get care from regularly and can easily stay in-network, then choosing an HMO or EPO may mean a lower cost for you each month.
  • If you need the freedom to go outside a narrow network and still get some benefits from your coverage, then look at PPOs or a more flexible POS plan.

If this is still confusing (it’s like Greek to me) call Kauffman Insurance Group to get more assistance in selecting the right plan for you, your family, or your business. 

 

Call Kauffman Insurance Group at (866) 660-5578 to speak to a licensed agent.

 

Learn more about Kauffman Insurance Group: kauffmanins.com

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