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Common Insurance Plan Types – HMO, PPO, EPO

When shopping for health insurance plans, you have a lot of options for the type of coverage. The level of benefits these plans offer varies, as does the deductible that you’ll have to pay upfront. Choosing a healthcare plan comes with a handful of considerations. You should find a plan that you can tailor to both your pockets as well as their coverage. The order in which these plans proceed are as follows:

  • Bronze: These are the lowest cost plans pre premium, and require you to cover 40% of the costs yourself as the insurance company deals with the remaining 60% of costs.
  • Silver: Slightly more coverage, with the insurance company paying for 70% of the procedure while you pay 30%.
  • Gold: Move comprehensive coverage, paying for as much as 80% of the course, while you cover the other 20%.
  • Platinum: The most expensive monthly cost to you, but you only need to cover 10% of a procedure’s fees, as the insurance company covers 90% of the bill.

Insurance brands usually come in one of four different types of plans, regardless of the brand. These are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), Point-of-service (POS) plans, and High-deductible health plans (HDHPs). Each of these gives users different levels of freedom and coverage regarding their use. In this article, we’ll be exploring the first three types of health insurance plans in detail, the HMOs, PPOs, and EPOs.

Health Maintenance Organizations (HMOs)

HMOs have a selected network of healthcare providers that they utilize throughout the country. Because this list of healthcare providers is exclusive, you don’t have the option of choosing your practitioner. It MUST be one of the preferred providers. On the bright side, this also translates to less paperwork for you, as an individual. Typically, you deal solely with a primary care physician, and if you need a specialist, you must be referred to them from this physician. You don’t have the option of going to a specialist without a referral.

The list of doctors in an HMO’s plan can be quite extensive, especially for larger companies. There are usually a few options within your local area that you can rely on. Unfortunately, if you decide to see a physician or practitioner that isn’t in the approved list of providers, the HMO will not cover your costs. More often than not, you will have to cover the bills for your visit yourself. That’s why double-checking the list of preferred providers is so crucial when your coverage is with an HMO.

You’ll be expected to pay a premium every month. Bronze premiums come up to the least, and platinum premiums set you back the most. Depending on your plan, you may also be required to pay a deductible. The deductible is a set amount that you are required to pay before your insurance kicks in. Depending on your plan, you may have to pay copays or co-insurance for your visits. Copays and co-insurance are both counted towards your deductible.

Preferred Provider Organizations (PPOs)

PPOs offer a little more freedom in choosing your healthcare providers than HMOs. If you decide to see a specialist, you don’t need to get a referral from your primary doctor. There’s a preferred list of providers, but those doctors aren’t the only ones covered under a PPO plan. They’re just the ones that you’ll be paying less to see. With this increased amount of freedom comes the option to see any doctor you want, but the PPO will only cover the total percentage of your plan for doctors that appear on their preferred provider list.

Unfortunately, PPOs also bring with them higher levels of paperwork. HMOs don’t have any paperwork whatsoever, but PPOs have a bit more to fill out if you decide to see out-of-network doctors. Most of the penalties you’ll face will come from seeing out-of-network doctors since the PPO prefers to deal with doctors in its preferred list.

You’ll still be paying a premium depending on your plan premium level (bronze, silver, gold, or platinum). Some PPOs also have a deductible, but others waive that part of their agreement. Once more, out-of-network doctors will cost you more and might even have an added cost before the insurance takes over. Copay or co-insurance costs are also present. Out-of-network visits usually aren’t covered by the PPO directly. You have to foot the bill and fill out the paperwork for the PPO to reimburse you.

Exclusive Provider Organizations (EPOs)

EPOs are a middle-ground between the two previous coverage options. With an EPO, you get a moderate level of freedom to visit doctors and see specialists without a referral. On the other hand, you’re not covered for any out-of-network visits. They are usually offered by the same insurer as a PPO, but they cost a lot less. They do make exceptions for emergency cases when you may have to utilize emergency services that are not in their network. Aside from that, any out-of-network visits will have to be covered with your own funds.

With an EPO, you’ll be paying premiums based on the level of your plan, bronze being the cheapest, and platinum being the most expensive. Some EPOs waive deductibles, but it’s up to the EPO’s agreement with the client. You may have to ask if it’s not clearly stated. You will also have to pay copays or co-insurance. Unfortunately, this type of coverage doesn’t have a provision for out-of-network visits, and you’ll have to pay the bill for those visits yourself.

What Type of Insurance Is Best For Me?

When shopping for health insurance, you’ll see a lot of choices. Determining the right one for you will take some careful consideration. My Private Health Insurance can do most of the heavy lifting for you in narrowing down your choices. We can teach you about different types of insurance, let you browse our provider listing, and even get quotes, so you can figure out which suits your unique needs. Contact us today to find out more!