HMOs and PPOs and EPOs oh my!?

HMO, PPO, EPO, POS - what do these network types mean? It sounds confusing, but it mainly comes down to a few key points that distinguish these network types. Here's an overview:

 

An HMO (or “health maintenance organization”) is generally the most affordable, but least flexible network type. Here a few key concepts of a HMO:

  • You are required to select a primary care physician (or the insurance company can assign one for you) who is your first-stop for health needs. You will need a referral from your primary care physician to see a specialist.
  • If you choose to see a doctor outside of the network or without a referral, you will generally have to pay all costs out-of-pocket unless it is a true medical emergency or you have no other options.
  • The physician network is local.

A PPO (or “preferred provider organization”) is generally the most flexible, yet most expensive network type. Here a few key concepts of a PPO:

  • You do not need to select a primary care physician and you do not need referrals to see a specialist.
  • If you see an in-network provider, you will only be responsible for paying a portion of the bill (based on your plan's coverage structure).
  • If you choose to see a doctor who is outside the preferred network, you will generally have to pay a larger portion of the bill than you would for an in-network provider.
  • You will have access to out-of-state providers that are considered in-network.

An EPO (or “exclusive provider network”) is a hybrid of a HMO and a PPO. Here a few key concepts of an EPO:

  • EPOs are more flexible than an HMO, and are typically less expensive than a PPO.
  • Like a PPO, you do not need a referral to get care from a specialist.
  • Like an HMO, you are responsible for paying out-of-pocket if you seek care from a doctor outside your plan's network.

A POS (or "point of service”) is also a hybrid of a HMO and a PPO. Here are a few key concepts of a POS:

  • POS plans are more flexible than an HMO, and are typically less expensive than a PPO.
  • Like an HMO, you will need a referral from your primary care physician in order to see a specialist.
  • Like a PPO plan, you will have access to out-of-network providers (at an increased cost).
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