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Health insurance types–HMO, PPO, & EPO

AFFORDABLE CARE ACT PLAN TYPES

  HMO PPO EPO
Do I need to stay in-network? Yes No, but in-network is less expensive Yes
Does the plan pay for out of network care? No Yes No
Do I need a referral to see a specialist? Yes No No
Best for if You want one primary contact for health needs, lower premium You want choices in providers and specialists You don't want referrals to see specialists, but want slightly lower premium
 

HMO (Health Maintenance Organization)

  • You must select a PCP (primary care physician) who acts as a "gatekeeper". You see them first and need to get a referral to see a specialist.
  • Members must stay in the network, unless it’s an emergency situation. If they see someone outside of the network, the member would be responsible for the whole cost of treatment.
  • HMOs include Kaiser Permanente and CCHP.

A HMO plan is ideal for individuals who want a main contact for their health needs and who visit the doctor infrequently.

PPO (Preferred Provider Organization)

  • PPOs have a 'preferred doctor network' in the area. You can see any doctor, but you'll pay less by seeing an in-network doctor.
  • More flexibility when it comes to choosing physicians and specialists.
  • Premiums tend to be higher than an HMO.

A PPO plan works well for those who want more options, and don’t want to turn to a primary care physician in order to see a specialist.

EPO (Exclusive Provider Organization)

  • EPOs work like an HMO, but members don’t need a referral to see a specialist.
  • Members must stay inside their network of doctors in order for the services to be covered by insurance.

An EPO plan is ideal for an individual who wants more flexibility in provider choice, but wants to pay a lower premium than a PPO.

Quick tips

  • Have your provider list, and check it twice–if you have a specific doctor or specialist you go to often, make sure they’re on the provider list for the insurance plan you are applying for because you are locked into a plan for a year.

  • Understand and evaluate your medical bills–8 in 10 medical bills contain errors. If you believe something has been itemized incorrectly, make sure to call your doctor or the hospital to have this fixed.