Health Insurance Networks Explained
HMO (Health Maintenance Organization)
- Requires that you stay within a network of approved doctors and health care facilities
- Referrals are not needed to see in-network specialists for some plans
- Lowest premiums and co-payments of all health plans
- Access to the highest amount of benefits for a co-pay
- May not have to pay any deductible for ER visits, certain diagnostic tests and procedures, and medications
- Most cost effective plans for those who only seek preventive care and compliance with the Affordable Care Act.
- For those who are willing to go to only in-network physicians and hospitals
- HMO plans have the second most restrictive networks, behind EPO plans
EPO (Exclusive Provider Organization)
- Are smaller, independent provider networks
- You do not need a referral to see a specialist, and you don’t need to choose a PCP
- Have no out-of-network benefits unless an emergency arises
- Have the smallest network of providers and hospitals
- For those who do not see any out-of-network specialists
- Best for people who stay within a 50 -100 sq mile geographic area and don’t travel often
- For rural residents
POS (Point of Service)
- Must designate an in-network primary care physician to coordinate care and make referrals
- Offers some out-of-network coverage, with a wider network of specialists and facilities than HMOs
- Premiums are 50% more than HMOs, with a smaller network than PPOs
- When you want to use out-of-network providers, you must first satisfy a high annual deductible, before benefits pay out
- Despite the higher premiums, many POS plans require referrals to see out-of-network specialists, which could be difficult to get and is time-consuming, and doctor fees have to be paid in full, upfront.
- You must file your own insurance claims and keep track of receipts. Reimbursements can take three to six months.
- For people who use a lot of outpatient medical services, such as counseling, manipulations, etc
PPO (Preferred Provider Organization)
- You will not have to be tied to any primary health care physician.
- You will have access to the broadest networks and the largest number of facilities and physicians.
- Referrals not needed for specialists.
- You will pay a negotiated amount when using a participating provider
- Most expensive plans, with highest co-insurance and out-of-pocket costs
- Best for people who frequent out-of-network specialists and use HSAs
- Offers the most flexibility to go outside of the plan, for those willing to pay extra for the privilege.