What’s with the alphabet soup? What’s it all mean? How will it inform your choices?
Understanding the differences in these 3 plan types is essential in understanding health insurance in this new wacky market.
HMO
Say your toe hurts and you’re on an HMO (aka Health Maintenance Organization.) Where do you go first, the podiatrist? WRONG! With an HMO, you have to get prior approval and referral to a specialist from your PCP (Primary Care Physician.) And, there are NO out-of-network benefits ever, except for emergencies. HMO’s are a way for the insurance company to reduce costs by eliminating unnecessary testing and procedures by running everything by your PCP doctor.
At the end of the day, you have less control over your own medical care and it can be a time suck.
PPO
PPO’s (or Preferred Provider Organization) tend to have a richer doctor network and, by using these doctors, you get great price discounts. But it’s up to you to make sure your fave docs are IN-network. You can choose whatever doctors you like, whenever you like… no need for a PCP referral.
You can also choose to go to an OUT-of-network doctor, but you’ll pay more out of your own pocket. These doctors don’t have to discount their fees and there may be a separate (and higher!) deductible for out-of-network services.
But if you like being in charge of your own medical destiny, this could be a great plan for you!
And the new weird one you may not be familiar with . . .
EPO
EPO stands for Exclusive Provider Organization. An EPO network is a PPO-HMO mash-up. Benefits are available only IN the EPO network. Like a PPO network, you can pick and choose your own doctors at any time. But, like an HMO, there are NO benefits OUT of the network, except for emergencies.
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One last thing about the different plan types and doctor networks . . . if you are purchasing a plan on your state’s exchange for a tax subsidy to reduce your costs (in CA, it’s called Covered California,) you may see a difference in networks with plans purchased on the exchange. So do your research before purchasing and let that information guide your decision making. Just stay informed.
It certainly isn’t a rose, but being informed is certainly sweet! (Shakespeare fans, anyone?)
