As you shop for health insurance plans in the Marketplace, it is crucial that you understand their differences – this includes plan networks, premiums and deductibles.
Your health plan selection can influence how and when you receive care. Learn about HMO, PPO, and EPO options available to you.
HMO
HMO plans typically offer lower monthly premiums than traditional health insurance and feature lower deductibles or even no deductibles at all. They may also feature lower co-pays for office visits and prescription costs.
An HMO plan requires members to select a primary care physician (PCP) who will manage their healthcare and conduct regular check-ups, arranging referrals to specialists such as dermatologists. It’s important that members find someone they trust who falls within the HMO network when choosing a PCP.
HMO provider networks consist of doctors, hospitals, and other healthcare providers that agree to treat HMO plan members at discounted rates in return for membership of their HMO plan. This arrangement usually rests on the assumption that patients will use only providers within their HMO provider network for most or all their healthcare needs, except emergency situations.
Most HMO plans cover hospital, medical and preventive services provided by in-network doctors but will not reimburse members who use out-of-network providers; however, some HMOs now offer Point Of Service (POS) benefit plans that enable members to get reimbursement under similar terms to traditional indemnity insurance – with an individual deductible and copayment structure in place for out-of-network services received outside their plan’s network.
Your choice of health plan should meet both your needs and budget requirements. Consider what services and medications you require annually as well as their out-of-pocket costs before comparing annual costs between each option to determine which plan best meets them both.
PPO
Preferred provider organizations (PPOs) allow more flexibility when choosing doctors and hospitals than HMOs do, often featuring larger networks with no referral requirements for seeing specialists within those networks. Unfortunately, however, such freedom comes at the cost of higher monthly premiums and out-of-pocket expenses.
When selecting a PPO plan, it’s essential to carefully weigh its tradeoffs. Is freedom of doctor choice or keeping costs low more essential to you? Do you wish to continue seeing certain specialists, even if they fall outside your network? Answering such questions will help determine whether a PPO is best suited for you.
At this stage, another factor to take into account is whether or not you’ll be required to meet a deductible. Most PPOs require you to meet this deductible before your insurance kicks in; HMOs don’t usually include such requirements, although some might.
Understanding the difference between traditional PPOs and high-deductible health plans (HDHPs) is vitally important. HDHPs feature higher deductibles but lower monthly premiums. Plus, HDHPs allow for the creation of health savings accounts (HSAs). Understanding these differences will enable you to find a plan best suited to you.
EPO
EPO (Exclusive Provider Organization) plans are similar to HMO plans in that members must visit doctors and hospitals within their plan’s network, but do not restrict out-of-network care except during emergency situations. EPO plans can provide lower costs while still giving members direct access to specialists without referral from primary care doctors. They may be appropriate options for people looking for lower costs without minding visiting a smaller network of providers and hospitals.
EPO plans typically feature lower premiums than PPOs; however, they don’t cover care received outside their network, potentially increasing out-of-pocket expenses significantly. It is therefore vital to carefully research provider networks before joining an EPO plan.
Some EPO plans feature Health Savings Accounts that enable individuals to save money on healthcare expenses by contributing and withdrawing tax-free funds.
Finding the ideal health insurance is all about understanding your needs and budget. No matter if you prefer low costs and limited network access or high coverage with low monthly premiums, there’s sure to be a plan out there that meets them both! Lacie Glover is an insurance editor at NerdWallet with extensive expertise in healthcare and personal finance topics; she has written for USA Today, U.S. News & World Report and The Associated Press among others.
POS
POS health insurance plans combine HMOs and PPOs into a hybrid plan that gives individuals more freedom in selecting providers they’d like to see, with higher premiums that may be difficult to comprehend. If this type of coverage interests you, let eHealth help you find affordable POS plans that meet your specific needs.
A Point-of-Service plan (POS) offers all the flexibility of a PPO while still requiring you to visit a primary care physician (PCP), who coordinates your health care and provides referrals for network specialists. However, should you prefer seeing out-of-network specialists instead, your POS plan typically allows this as long as it costs more than an in-network provider would. In addition to meeting an annual out-of-pocket maximum (AOM), which limits how much out of pocket care will cost annually.
No matter which plan you select, having health insurance to cover unexpected medical expenses is a necessity. Compare POS plans and other types on eHealth’s free online marketplace to find one that best fits your budget – our licensed agents are also on hand if needed to assist. Start shopping now!
