Understandably, there is a lot of confusion about the types of plans because there are no industry-wide definitions and because state standards are different.
To help you better understand the different types of plans, here are some generalities:
Health Maintenance Organizations (HMO): HMOs only cover care provided by doctors and hospitals within the network.
Preferred Provider Organizations (PPO): PPOs cover care in and out of the plan provider’s network. There is typically a higher percentage of the cost for care provided out-of-network, paid for by the members.
Exclusive Provider Organizations (EPO): EPOs generally do not cover care outside of the plan provider’s network. They are similar to HMOs, but members may not need a referral to see a specialist.
Point of Service (POS): POS plans often combine aspects of HMOs and PPOs. There may be coverage for out-of-network care that comes with higher cost sharing. Members also may need a referral to see a specialist.
There is a lot of variety from one plan to the next, despite how the plans are labeled.
When looking at plans, make sure to ask some basic questions about coverage, such as:
- If members are required to have a primary care physician,
- If members are required to get referrals for specialists or services,
- If any healthcare services need to be pre-authorized,
- If there is out-of-network coverage, and
- If there is out-of-network coverage, does spending count toward the out-of-pocket maximum?
All this month we are answering your questions and we will be answering even more in this month’s webinar Ask Lori-Ann Your Healthcare Questions on January 27, 2016 at 2 p.m. Eastern. Reserve your spot now! Bring your questions to the webinar or submit them in advance by email or on Facebook or Twitter.