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