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Health Insurance Networks Explained

HMO (Health Maintenance Organization)

  • Requires that you stay within a network of approved doctors and health care facilities

  • 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.

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