Part 3: Biggest Questions of 2015 Insurance Open Enrollment

July 30, 2014 Marijah Adams Cleek

Should I choose an EPO, an HMO, a PPO, or a POS insurance plan?

Have you ever called to make a new patient appointment with a healthcare provider only to be asked if you have a PPO, HMO, POS, or EPO plan? For me, this question was often times answered, “Um… I have no idea.” Oh, how confusing three letter acronym insurance plans are.

Fear not! I am here to break it down.

What is an EPO?

EPO stands for Exclusive Provider Organizations. This is one of the most economical plans available. Out-of-pocket costs are kept low, so low that some insurance companies don’t require deductibles, copays, or coinsurance.

This is because insurance companies create partnerships with healthcare providers, ensuring lower rates for patients and guaranteeing business for doctors. Because of this, patients must shop for in-network providers; there are no out-of-network benefits.

Services are limited to preventative and medically necessary visits, but EPO plans don’t require patients to choose a primary care provider (PCP), fill out any claim paperwork, or receive referrals before seeing a specialist. However, pre-authorization from the insurance company is often required.

There are three exceptions to the in-network rules:

  1. If there is not an in-network specialty provider in your area, call your EPO provider and let them know. They will often allow you to seek treatment from an out-of-network provider for little or no additional charges.
  2. If you switch insurance to or begin an EPO plan in the middle of a series of complex care treatments with a doctor who is not in the EPO network, the insurance provider can determine if you can finish the remainder of your care with the same doctor.
  3. If there is a true emergency (like if a kangaroo gets scrappy with your face, resulting in several broken bones and the need for immediate medical attention), you can go anywhere.

What is an HMO?

An HMO is a Health Maintenance Organizations plan, which often has lower monthly premiums and out-of-pocket expenses. In fact, most HMO plans only charge copays for doctor office visits. Plus, HMO doctors don’t get paid unless they file a claim with the insurance provider, so you shouldn’t have to deal with any paperwork after your appointment.

Different from EPOs, HMOs generally require you to select a PCP and receive referrals. PCPs mostly consist of family physicians, internal medicine physicians, pediatricians, and in some plans, gynecologists who offer basic healthcare for ladies.

These plans also require you to use healthcare providers and facilities in-network, unless it’s an emergency case. Out-of-network doctors can be visited, but they may cost the patient the full out-of-pocket cost. And the drugs (prescription drugs of course) may or may not be covered; it varies by plan.

What is a PPO?

Preferred Provider Organization (PPOs) plans have higher monthly premiums and out-of-pocket costs, but they offer the most flexibility and choice. Copays are nearly always incorporated, but deductibles vary depending on which plan you choose.

The insurance companies contract with a network of “preferred” providers (hence the name) for shoppers to choose from. Since all the physicians are approved ahead of time, no PCP or specialist referrals are required. Nonetheless, expensive procedures, like an MRI or ultrasound, require prior approval beforehand.

But back to the flexibility, in-network doctor visits usually only require an annual deductible and a copay. Out-of-network doctors aren’t off limits, as they are in EPOs. If you choose to go that route, you will pay a higher out-of-pocket amount or file a claim for reimbursement from the insurance company.

What is a POS?

Last, but most certainly not least, Point of Service (POS) plans are the fusion of HMO and PPO. Like the HMO, these plans require a designated PCP and referral for specialist visits; like the PPO, patients can go outside of the network for services. Out-of-network costs are the responsibility of the patient, however, unless referred to by your PCP.

POS plans aren’t usually saddled with deductibles, and preventative care is often included, a trend expected to keep growing to save health insurance providers more money over the long haul.

Patients seeking in-network care generally have low cost sharing (out-of-pocket costs), but those wanting out-of-network care without a referral can expect to pay much higher sums.

Like what you read? Here are some more blogs you might be interested in:

Part 1: The Biggest Questions of 2015 Insurance Enrollment Period- Deductibles vs.  Out-of-Pocket Maximums

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