Or, to put it another way, you may not be covered for a visit to a specialist without that referral from the PCP first. If you need to see a specialist, you would first visit your PCP, who would then refer you to an in-network specialist. The PCP must be in the HMO’s network, and this doctor will be the provider you see any time you need medical treatment. Many HMOs require members to choose a PCP to manage their overall care. Primary Care Physicians (PCP) and ReferralsĪs mentioned before, one key difference between these different healthcare plans is whether they require members to choose a primary care physician (PCP) to manage their overall care. That said, PPO members can save money by seeing doctors that are within the PPO network, as out-of-network providers will generally cost more. HMOs, EPOs, and POS plans often have no deductible or a low deductible. They also almost always have an annual deductible, or an amount the insured member must pay out-of-pocket before the insurance plan kicks in and pays any claims. PPOs, which give members the most choice in terms of which providers they see, often have still higher monthly premiums and copays. In part due to their out-of-network benefits, POS plans typically come with slightly higher premiums. Related Article: 3 Questions To Ask Before Picking Your Company's Health Insurance However, it’s important to remember that these lower costs are gained by using in-network providers. These plans also tend to have lower copays and coinsurance than other health insurance plans. Since the in-network providers all agree on the pricing level for their services, this helps the HMO/EPO to keep costs low. HMOs and EPOs tend to have lower monthly premiums. The less flexibility, the less expensive. While every plan differs, in general, the more flexibility a plan offers - e.g., covering some percentage of out-of-network care or allowing patients to see a specialist without a referral - the more it will cost in terms of premiums and cost-sharing (e.g., deductibles, coinsurance, and copayments).
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Unlike HMOs, EPOs usually do not require patients to select a primary care physician and do not require referrals to see specialists.Ĭost is a major factor in choosing between plans. Like HMOs, these plans do not pay for out-of-network care (except in some emergency circumstances). EPO: Exclusive Provider OrganizationsĮPO also provides access to a network of providers. While similar to HMO, POS plans provide more geographic flexibility (as well as out-of-network benefits).
POS plans are typically gated, meaning a member must choose a primary care physician who is the “point of service.” However, this is not always the case.Īs with Preferred Provider Organizations or any other plans covering both in- and out-of-network services, if you choose to access healthcare services from providers outside of your network, you'll have higher out-of-pocket costs, and not all services may be covered. POS provides in-network care like HMO, but also allows patients to receive out-of-network care under certain circumstances. Patients are also not required to choose a single primary care physician, and do not need a referral to see specialists. In other words, members of a PPO can see any doctor they want or visit any hospital, although providers outside of the network will tend to cost more. However, unlike an HMO, a PPO allows patients to access treatment from providers outside of the network.
PPOs also offer access to a network of doctors and providers who accept payment at a certain rate for members. HMO plans typically require patients to have referrals from a primary care physician, and won’t cover out-of-network care. The providers agree to accept payment at lower rates for the services they provide to plan members, which sets costs and keeps them in check. HMOs begin by establishing a local network of doctors, hospitals, and other providers.