Plan

April 25, 2018 Posted by

A benefit your employer, union or other group sponsor provides to you to pay for your health care services. Plans include:

PPO Plan: means “Preferred Provider Organization.” Like the name implies, with a PPO plan you’ll need to get your medical care from doctors or hospitals on the insurance company’s list of preferred providers if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it’s up to you to make sure that the health care providers you visit participate in the PPO. Services rendered by out of network providers may not be covered or may be paid at a lower level. A broad variety of PPO plans are available, many with low monthly premiums.

A PPO may be right for you if:

  • Your favorite doctor already participates in the PPO
  • You want some freedom to direct your own health care but don’t mind working within a list of preferred providers

HMO

HMO means “Health Maintenance Organization.” HMO plans offer a wide range of health care services through a network of providers that contract exclusively with the HMO, or who agree to provide services to members at a pre-negotiated rate. As a member of an HMO, you will need to choose a primary care physician (“PCP”) who will provide most of your health care and refer you to HMO specialists as needed. Some HMO plans require that you fulfill a deductible before services are covered. Others only require you to make a copayment when services are rendered. Health care services obtained outside of the HMO are typically not covered, though there may be exceptions in the case of an emergency.

An HMO may be right for you if:

  • You’re willing to play by the rules and coordinate your care through a primary care physician
  • You’re looking for comprehensive benefits at a reasonable monthly premium
  • You value preventive care services: coverage for checkups, immunizations and similar services are often emphasized by HMOs

Network

A “Network” plan is a variation on a PPO plan. With a Network plan you’ll need to get your medical care from doctors or hospitals in the insurance company’s network if you want your claims paid at the highest level. You will probably not be required to coordinate your care through a single primary care physician, as you would with an HMO, but it’s up to you to make sure that the health care providers you visit participate in the network. Services rendered by out of network providers may not be covered or may be paid at a lower level.

A Network plan may be right for you if:

  • Your favorite doctor already participates in the network
  • You want some freedom to direct your own health care but don’t mind working within a network of preferred providers

POS

POS stands for “Point of Service.” POS plans combine elements of both HMO and PPO plans. As a member of a POS plan, you may be required to choose a primary care physician who will then make referrals to specialists in the health insurance company’s network of preferred providers. Care rendered by non-network providers will typically cost you more out of pocket, and may not be covered at all.

A POS plan may be right for you if:

  • You’re willing to play by the rules and possibly coordinate your care through a primary care physician
  • Your favorite doctor already participates in the network

EPO 

 An EPO is a Exclusive Provider Organization. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside of the network for care. There are no out-of-network benefits.

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