There are several health plans that are sold by insurance companies with
some of the same features. Three managed health care plans, a Health
Maintenance Organization (HMO), Preferred Provider Organization (PPO) and Point
of Service (POS), along with an Exclusive Provider Organization (EPO), all
provide members with networks of doctors that they can visit and receive
greater insurance benefits. However, each plan has its benefits that address
the needs of different health care applicants.
some of the same features. Three managed health care plans, a Health
Maintenance Organization (HMO), Preferred Provider Organization (PPO) and Point
of Service (POS), along with an Exclusive Provider Organization (EPO), all
provide members with networks of doctors that they can visit and receive
greater insurance benefits. However, each plan has its benefits that address
the needs of different health care applicants.
Differences
between HMOs and Other Plans
between HMOs and Other Plans
HMOs
are the most restrictive of the three managed health care plans. Members must
receive medical care by doctors within their provider networks. By staying
in-network, members receive the highest amounts of insurance benefits that
result in no deductibles and little to no co-payments. HMO plans require
members to choose Primary Care Physicians (PCPs) from their provider networks.
PCPs are in charge of their patients’ medical decisions. They can refer them to
other doctors and specialists who operate out-of-network, and members will
receive insurance coverage. However, if they decide to go out of network
without referrals from their PCPs, members will be solely responsible for all
incurred medical costs.
are the most restrictive of the three managed health care plans. Members must
receive medical care by doctors within their provider networks. By staying
in-network, members receive the highest amounts of insurance benefits that
result in no deductibles and little to no co-payments. HMO plans require
members to choose Primary Care Physicians (PCPs) from their provider networks.
PCPs are in charge of their patients’ medical decisions. They can refer them to
other doctors and specialists who operate out-of-network, and members will
receive insurance coverage. However, if they decide to go out of network
without referrals from their PCPs, members will be solely responsible for all
incurred medical costs.
Differences between PPO and HMOs Plans
The
most flexible managed health care plans are PPOs. Members are not required to
stay in-network for health care and do not have to use PCPs. The insurance
benefits are not as high as HMOs because members will have to pay deductibles
and co-payments when visiting network doctors. They can go out of network for
care and still receive insurance coverage; however, it will be less than what
they would have received for staying in-network. In fact, members can be
responsible for up to 40 percent of their medical bills out-of-pocket by going
out of network.
most flexible managed health care plans are PPOs. Members are not required to
stay in-network for health care and do not have to use PCPs. The insurance
benefits are not as high as HMOs because members will have to pay deductibles
and co-payments when visiting network doctors. They can go out of network for
care and still receive insurance coverage; however, it will be less than what
they would have received for staying in-network. In fact, members can be
responsible for up to 40 percent of their medical bills out-of-pocket by going
out of network.
Similarities Of HMOs, POS and PPO Plans
POS
plans are considered hybrids as they are made up of elements from both HMO and
PPO plans. Like HMO plans, some POS plans require members to choose PCPs and
offer the highest amounts of insurance benefits by staying in network. Like PPO
plans, however, members are able to go out of network and still receive
insurance coverage, but the amounts will be lower. Members do not have to get
referrals for non-network care even if they have PCPs. However, out-of-pocket
expenses, such as deductibles and co-payments, are substantially higher for
members who do not get referrals for non-network care.
plans are considered hybrids as they are made up of elements from both HMO and
PPO plans. Like HMO plans, some POS plans require members to choose PCPs and
offer the highest amounts of insurance benefits by staying in network. Like PPO
plans, however, members are able to go out of network and still receive
insurance coverage, but the amounts will be lower. Members do not have to get
referrals for non-network care even if they have PCPs. However, out-of-pocket
expenses, such as deductibles and co-payments, are substantially higher for
members who do not get referrals for non-network care.
Similarities between HMOs and EPO Plans
EPO
plans work similar to HMOs as their members are required to stay within their
networks for health services and choose PCPs to coordinate their medical care.
Members do not have to pay deductibles, and they will pay small co-pay amounts
for network care and can only go out of network and receive insurance coverage
if they were referred. However, EPO plans provide fewer physician networks to
their members than HMO plans, and their premiums are cheaper as well. Another
difference is HMO insurers make monthly payments to their doctors while EPO
plans pay their physicians only when services are rendered.
plans work similar to HMOs as their members are required to stay within their
networks for health services and choose PCPs to coordinate their medical care.
Members do not have to pay deductibles, and they will pay small co-pay amounts
for network care and can only go out of network and receive insurance coverage
if they were referred. However, EPO plans provide fewer physician networks to
their members than HMO plans, and their premiums are cheaper as well. Another
difference is HMO insurers make monthly payments to their doctors while EPO
plans pay their physicians only when services are rendered.