Navigating Health Insurance: What Are EPOs, PPOs, and HMOs?

When a person is first approaching the subject of health insurance, all the different terminology can make their head spin. In this article, we’ll help you grasp the differences between EPOs, PPOs, and HMOs.

An EPO is an exclusive provider organization. This is a health insurance plan that offers a local network of doctors and hospitals that you can choose from. The networks for EPOs are usually larger than the networks for HMOs. Preferred Care Providers are usually required. Your total costs are usually lower than with a PPO. Doctor visits won’t be covered outside your network except in an emergency.

A PPO is a preferred provider organization. A PPO generally has a larger network of providers so there are more for you to choose from. Your premium and out-of-pocket costs are usually higher. You can see an out-of-network provider at a higher cost to you. Compared to other types of insurance, costs are generally higher but you have more freedom of choice.

A HMO is a health maintenance organization. With an HMO, you need to choose a Preferred Care Provider to coordinate your care. All your practitioners must be chosen from their network. Referrals are required before you see a specialist. These plans generally have higher deductibles and lower premiums. This is one of the cheapest types of health insurance but might not be the right choice for a person who is frequently away from home.

Choosing the Right Health Insurance for You

When you are looking at different types of insurance, you need to know which of these three types you are considering. The rules that control what’s covered and what’s not covered are very rigid in each plan. To ensure your care is covered by your insurance, it’s vital to follow their rules.

With EPOs and HMOs, you must ensure that the practitioners you want are in-network. With PPOs, you should be prepared for your costs to be higher if you choose an out-of-network practitioner. Otherwise, you could find that your claims are rejected.

If certain practitioners are important to you, find out if those practitioners are included in a particular insurance plan’s network before you enroll to prevent any unpleasant surprises later.

One important point to note: When you choose an EPO plan, these plans require admission to specific hospitals only. This applies even to emergency care. That’s why this plan is not the best one for a person who is away from home often.

To get the maximum coverage for your healthcare, you must know and use your network. So check the network for your preferred practitioners and hospitals ahead of time and then, for the best coverage and lowest costs, utilize only those practitioners.

State Differences in Health Insurance

MBhealth is licensed to help people find health insurance in both Missouri and Illinois.

In Missouri, all plans under the ACA are EPOs.

In Illinois, most plans under ACA are EPOs. There are a few PPO programs.

There are other insurance plans available in these states but when a person is looking for a plan under the ACA, these limitations apply.

What about Medicare? Don’t expect these guidelines to apply to Medicare programs. All Medical programs utilize a different terminology. These guidelines apply to individual health insurance policies only.

Get Help Simplifying Your Enrollment

At MBhealth, we help our clients navigate these differences all the time so they can get the best plan for themselves and their families. We work for our clients only, never for the insurance companies. When you’re looking for health insurance, we can make it simple and even relatively painless. Give us a call at (314) 544-5400 when you need guidance during what we know can be a confusing process.

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