Conquering Health Plans: HMO, PPO, & EPO

Health Maintance Organization (HMO):

With an HMO plan, you pick one primary care physician. All your health care services go through that doctor. That means that you need a referral before you can see any other health care professional, except in an emergency. Visits to health care professionals outside of your network typically aren’t covered by your insurance.

For instance, if you were to get a skin rash, you wouldn’t go straight to a dermatologist. You would first go to your primary care physician, who would examine you. If your primary care physician can’t help you, he or she will give you a referral to a trusted dermatologist in your network that will. 

One exception to this is that women don’t need a referral to see an obstetrician/gynecologist in their network for routine services. (aka: Pap tests, annual well-woman visits and obstetrical care). Coordinating all your health care through your primary care physician means less paperwork and lower health care costs for everyone. 

Preferred provider organization  (PPO): 

PPO plans give you flexibility. You don’t need a primary care physician. You can go to any health care professional you want without a referral—inside or outside of your network. Staying inside your network means smaller co-pays and full coverage. If you choose to go outside your network, you'll have higher out-of-pocket costs, and not all services may be covered. 

Exclusive provider organization (EPO):

EPO plans combine the flexibility of PPO plans with the cost-savings of HMO plans. You won't need to choose a primary care physician, and you don't need referrals to see a specialist. But you'll have a limited network of doctors and hospitals to choose from.

EPO plans don't cover the care you get outside your network unless it's an emergency. (Note: It's important to know who participates in your EPO plan's network. If you go to a doctor or hospital that doesn't accept your plan, you'll pay all costs.)

Thoughts:

HMO's tend to be more affordable, but the patients usually have less coverage and more restrictions. Although PPO's are more expensive than HMO's and there is a chance of deductible, the patient has more flexibility and greater care.  

Both HMO and PPO have access to a network of doctors, hospitals and other healthcare providers. Only PPO gives the patient the ability to see the doctor you want without PCP to authorize treatment or referral from a PCP to see a specialist. PPO has also the possibility of coverage for medical expenses outside of the plans network.  HMO has a low or no deductible with generally lower premiums. 

When deciding between these plans one should consider income, availability/type of plan in your area, and most importantly your medical needs.

 If you’re looking at an HMO, take a close look at the network to determine if the choices of doctors and medical facilities are enough to meet your needs. A PPO gives you more freedom, including the potential to be covered for medical bills outside the network, but your costs may be higher.

I prefer having the flexibility of seeing specialists whenever I want without having permission of my primary doctor. Therefore, the PPO plan works best for me. However, depending on your finacial status and preference you could chose HMO or EPO. 



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