UNDERSTANDING PPO, HMO, EPO, AND POS NETWORKS WHEN IT COMES TO HEALTH INSURANCE

If you have health insurance or are simply looking for coverage, you have probably heard the terms “network” or “provider network.” Even if you have encountered abbreviations like HMO, PPO, EPO, or POS, it may not be entirely evident how choosing one over the other alters access to medical care and may affect out-of-pocket payments.

Which healthcare network is the best for you when choosing health insurance in Coral Gables? Health insurance providers offer network access to lower costs for the insurance company and you, the patient, covered by the medical insurance plan. The insurance provider can control costs by negotiating lower prices for services, which might result in fewer out-of-pocket expenses for you. Doctors, hospitals, and other healthcare institutions that have agreed to offer negotiated pricing for services to insureds of particular health insurance plans might be considered part of a provider network.

You should be familiar with the following four types of networks: HMO, PPO, EPO, and POS. We explain them below, but be aware that each health insurance provider may have different terms and definitions.

Table of Contents

PPO

PPO stands for preferred provider organization. PPO plans often have the most extensive networks and provider access flexibility. They are typically more expensive as well. Here are the characteristics of PPO plans:

  • Greater network: Compared to other plan categories, the network of providers is typically more extensive.
  • Not requiring referrals: Members do not require a referral to see a specialist.
  • Though usually covered, out-of-network care has higher deductibles and coinsurance fees.
  • Higher prices: Because a PPO offers the most flexibility in giving members comparatively unrestricted access to an extensive range of providers, PPO premiums are frequently more expensive than the other types of coverage.
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HMO

HMO stands for Health Maintenance Organization. HMOs typically have the most restrictions out of the several types of plans, but they also usually have lower overall prices. The HMO plan overview is as follows:

  • Typically, an HMO has a smaller provider network than a PPO.
  • You need referrals: To see a specialist, members usually need a referral from their primary care physician (PCP).
  • There is no coverage for out-of-network care unless it is an emergency.
  • Lower prices: Since HMO plans tend to be the most constrained regarding members’ access to providers, they frequently have the lowest monthly costs.

EPO

EPO stands for the exclusive provider organization. If you stay in-network with an EPO program, you can see any provider without needing a primary care physician or referral. An EPO does not offer coverage outside its network. Read on to learn more about EPO medical insurance plans:

  • The network’s size is similar to PPO in most respects but without outside the network coverage.
  • No referrals required: Members do not require a referral to see a specialist.
  • There is no coverage for out-of-network care unless it is an emergency.
  • Costs: Premiums are often higher than HMOs but cheaper than PPOs.

POS 

This refers to the Point of Service. Features of POS plans vary significantly from one provider to the next. They can occasionally exclude out-of-network coverage, demand referrals, and have variable prices often higher than HMOs and lower than PPOs. Here is a summary:

  • Network size: they are smaller than PPO networks.
  • Referrals could be required: There are different referral requirements for each plan.
  • The cost-sharing for out-of-network care is typically higher for the member.
  • Costs: Compared to PPOs, premiums are typically lower.
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The definitions listed above, however, are just broad tendencies and by no means absolutes. You might find plans that don’t exactly fit into the main categories because no federal standards or regulations distinguish between the different plan kinds. However, there are many factors to consider, therefore, relying on Del Toro Insurance experts is advisable. Also, study the small print to learn how your plan’s options operate.

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