Outlined below is a brief guide to help you understand and sort through the various differences between EPOs, PPOs and HMOs – the three most common types of health insurance plans in the United States. Once you have some general knowledge about these different plans, you’ll be able to make an informed decision as to which one will grant you and your family the conveniences and advantages you need.
Preferred Provider Organization (PPO)
If you’re looking for an insurance plan that offers flexibility above all, then a PPO plan may be the ideal option for you. One of the primary benefits of a PPO plan is that you can schedule appointments with medical professionals – both inside and outside your network – in any and all specialties without a referral. This can be especially beneficial for individuals with busy schedules, as many of us have difficulty finding the time to visit a primary care physician merely to get a referral to a specialist.
While you can see specialists both in and outside your network, it’s best to try and stay in-network whenever possible. Doing so will ensure you receive full coverage for lower copays, in contrast to going out-of-network which means you’ll not only pay more out of pocket but that you’ll also run the risk of some services not being covered.
Exclusive Provider Organization (EPO)
For many individuals, EPO plans can offer the best of both worlds – they provide the cost-effectiveness of HMO plans without sacrificing the flexibility of PPO plans. One potential drawback is that the network of health care professionals to choose from is rather restricted, and the only time you’ll be able to see a provider outside your network and still be covered is if it’s an emergency.
That being said, many people enjoy the fact that you don’t have to choose a primary care physician with this plan, and that you also have the freedom to see an in-network specialist without obtaining a referral. Patients with EPO plans can reap the major benefits of both PPO and HMO plans so long as they stay up to date with which providers and facilities are in-network, as seeing an out-of-network provider for even the simplest medical services will result in a hefty bill.
Health Maintenance Organization (HMO)
Unlike PPO and EPO plans, patients with HMO insurance must choose a primary care physician and go through him or her for all their health care needs. If you want or need to see a different provider or specialist, you must first obtain a referral from your primary care physician, unless it’s an emergency, in which case you do not need a referral. Services provided by out-of-network providers are not generally covered, meaning you will likely pay more out of pocket just as you would with an EPO plan.
For women, there is one exception to the rule of having to see your primary provider prior to scheduling an appointment with a different physician. They can see an in-network OB/GYN for routine services and procedures without first obtaining a referral.
The primary benefit of HMO plans is that they’re more cost-effective than both EPOs and PPOs, due mainly to the fact that all your health care needs are coordinated through your one primary care physician – so you can look forward to lower health care bills and less paperwork.
Deciding Which Plan Is Right for You – A Quick Recap
If flexibility and having the freedom to see any specialist you wish without obtaining a referral is what you want, a PPO plan may be best. If you don’t mind having a smaller network of health care professionals to choose from and you’d like to have the flexibility of not needing referrals while also saving money, you should consider an EPO plan. If you like the more hands-off approach of having all your care needs overseen/coordinated by one primary care physician while also saving money, an HMO plan is the way to go.
If you still have questions about which plan will work best for you and your family’s unique needs, rest assured that we at Primary Care Insurance Solutions are here to help. Our friendly and knowledgeable health insurance experts are passionate about helping individuals like you navigate the oftentimes confusing process of selecting a health insurance plan and will work diligently to help you determine which one is best for you and your loved ones.
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