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Types of Insurance Plans

Health Insurance Types EPO HMO POS PPO
The doctors and hospitals you go to for medical services are known as "providers." Health plans provide access to certain contracted doctors and hospitals that are referred to as your "network" or "in-network providers." Network sizes, costs of services, and referral protocols depend on plan type.
Description EPO stands for Exclusive Provider Organization. EPOs give you "exclusive" access to a list of health providers. You must stick to providers on that list, or the EPO won’t pay. Think of an EPO as similar to a PPO but without the perk of out-of-network care except in emergencies. HMO stands for Health Maintenance Organization. HMOs tend to have low monthly premiums and low cost-sharing, but they require referrals from your primary care provider (or PCP) and won’t pay for care out-of-network services except in emergencies. POS stands for Point of Service Plan. Like an HMO but less restrictive, you’re allowed to get care out-of-network like with a PPO. Like HMOs, many POS plans require you to have a PCP referral for all care whether it’s in- or out-of-network. PPO stands for Preferred Provider Organization. PPOs give you a network of providers they prefer, but they’ll still pay for out-of-network care. They're pretty flexible in letting you choose your own health care providers, but you do pay higher monthly premiums and have higher cost-sharing.
Network Size
Monthly Premium Amount
Description Allows you to see any doctor, any time. An EPO negotiates discounts with doctors, hospitals and other providers, who then become part of the EPO network. You choose a primary care provider (PCP) affiliated with your plan (usually a general practitioner) to coordinate your care. Generally, you must receive a referral from your PCP before visiting a specialist even within your provider network. Allows you to see any doctor, any time. A PPO negotiates discounts with doctors, hospitals and other providers, who then become part of the PPO network. Hybrid of HMO & POS, these plans allow you to use a PCP to coordinate your care, or you can self-direct your care at the “point of service.”
Must have a primary doctor No Yes Yes No
Requires a referral to see a specialist Not Usually Yes Usually No
Drunk Unicorn
Pre-Authorization
For many situations like, in-patient or out-patient operations, various testing, lab work, x-rays, MRI, etc.
Varies from plan to plan, except no pre-authorization needed for an emergency situations. Not usually required. If required, PCP does it. No pre-authorization needed for an emergency. Not usually. If required, PCP likely does it. Out-of-network care may have different rules. Except no pre-authorization needed for an emergency situations. Yes, except no pre-authorization needed for emergency situations.
Deductible You have in-network deductibles and are responsible for anything out-of-network (unless it's an emergency.) No deductible for in-network providers but are responsible for anything out-of-network (unless it's an emergency.) You have both in-network and out-of-network deductibles. Some PPOs may have a deductible. You may have to pay a higher deductible if you visit an out-of-network provider.
In-Network Coverage Pay either a set co-payment, or coinsurance, which is a percentage of the cost of the visit. You will pay this amount up front when you visit your provider. You generally only have a co-pay when you visit in-network providers, so your out-of-pocket costs are usually lower with an HMO than with other plans. Pay either a set co-payment, or coinsurance, which is a percentage of the cost of the visit. You will pay this amount up front when you visit your provider. Pay either a set co-payment, or coinsurance, which is a percentage of the cost of the visit. You will pay this amount up front when you visit your provider.
Out-of-Network Coverage
Covers little or nothing outside of the network with the exception of an emergency.

Covers little or nothing outside of the network with the exception of an emergency.
  • A higher deductible than for in-network services.
  • A percentage (coinsurance) of the out-of-network “allowed amount” for the service you need. This percentage may be higher than for in-network services. For instance, instead of paying 20% of the allowed amount, you might have to pay 30% PLUS the full difference between the allowed amount and your provider’s actual charge, which could be much higher – and will almost certainly be higher than your plan’s contracted rate for in-network care.
  • Also may require PCP referral.
  • A higher deductible than for in-network services
  • A percentage (coinsurance) of the out-of-network “allowed amount” for the service you need. This percentage may be higher than for in-network services. For instance, instead of paying 20% of the allowed amount, you might have to pay 30% PLUS the full difference between the allowed amount and your provider’s actual charge, which could be much higher – and will almost certainly be higher than your plan’s contracted rate for in-network care.
Example 1: You find a strange mole on your body

You can make an appointment at any dermatologist that accepts your insurance and it will be covered. You can make an appointment with your PCP to determine what to do. If they deem it necessary, they will refer you to an in-network specialist (in this case, a dermatologist) for it to be covered. You can make an appointment with any in-network dermatologist or see your PCP first for a referral. Both are covered, but getting a referral may cost you less. You can make an appointment at any dermatologist that accepts your insurance and it will be covered.
Example 2: You get the sniffles while traveling domestically. You can make an appointment at any in-network doctor that accepts your insurance and it will be covered. If you're traveling, you're probably too far to see your PCP for a referral. Try contacting your PCP to see if you can get a referral for an in-network provider in the area you're traveling in. You can make an appointment with any in-network provider or contact PCP first for a referral. You can make an appointment at any provider that accepts your insurance and it will be covered.
Example 3: You get badly injured while traveling abroad

All health insurance plan types cover emergency care no matter where you are, even if you are tended to by an out-of-network provider, which is likely the case if you're traveling outside of the country. The definition of "emergency" can differ though, so check with your health insurance to see if your "emergency" will be covered. Additionally, you may want to see if your insurance company offers temporary packages for traveling abroad (or even domestically.) Same Same Same
The bottom line EPOs have some of the benefits of a PPO minus the out-of-network coverage. You'll save on your premium but it'll cost if you go out of network. Lower out-of-pocket costs but you have no control over going to specialists if your PCP doesn't approve the referral. If you have to go out-of-network, your costs can add up fast. It’s also important to remember that since an HMO’s network is limited to a specific area, it may not be right for you if you spend part of the year living somewhere else. Lower costs up front and you have the option of going out-of-network if you need to. A POS may also be a good choice if you spend part of the year living somewhere else. Flexibility to visit a range of different providers without getting a referral first. A PPO might be a good choice if you have preferred doctors or specialists that aren't all found within one network.
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