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HMO Vs.
PPO

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HMO, PPO, EPO or an HSA Plans?

That’s enough abbreviations to send someone running for the hills.  Let’s break it down for you.

  1. HMO stands for health maintenance organization.
  2. PPO stands for preferred provider organization.
  3. EPO stands for exclusive provider organization.
  4. HSA stands for Health Savings Account

All these plans use a network of physicians, hospitals and other health care professionals to give you the highest quality care. The difference between them is the way you interact with those networks.

HMO plans

With an HMO plan, you pick a  primary care physician. You need a referral before you can see a specialist, except in an emergency. Visits to outside of your network typically aren’t covered.

For example, if you have a stomach ache, you  wouldn’t go straight to a gastroenterologist.  You would first go to your primary care physician, who‘d examine you. If your primary care physician can’t help you, he or she will give you a referral to a gastroenterologist within your network that will.

One exception to this is that women don’t need a referral to see an obstetrician/gynecologist, or OB/GYN, in their network for routine services such as Pap tests, annual well-woman visits and obstetrical care.

PPO plans

PPO plans give you flexibility. You don’t need a primary care physician. You can go to any health care professional you want without a referral—inside or outside of your network.

Staying inside your network means smaller copays and full coverage. If you choose to go outside your network, you’ll have higher out-of-pocket costs, and not all services may be covered.

EPO plans

EPO plans combine the flexibility of PPO plans with the cost-savings of HMO plans. You won’t need to choose a primary care physician, and you don’t need referrals to see a specialist.

But you’ll have a limited network of doctors and hospitals to choose from. And EPO plans don’t cover care you get care outside your network unless it’s an emergency.

It’s important to know who participates in your EPO plan’s network. If you go to a doctor or hospital that doesn’t accept your plan, you’ll pay all costs.

HSA plans

HSA (Health Savings Account) plans behave similarly to Bronze plans in that all services are deductible exposed and usually these are high deductibles.  HSA plans provide a tax advantage to the insured as the IRS allows a yearly tax free contribution. HSA holders can choose to save up to $3,350 for an individual and $6,650 for a family (HSA holders 55 and older get to save an extra $1,000 which means $4,350 for an individual and $7,650 for a family) – and these contributions are 100% tax deductible from gross income.

POS plans

POS plans combine HMO and PPO behaviors.  You could have a family of co-pays like an HMO, no referrals required and the majority have national networks and or will provide out of network coverage.

Which one is right for me?

This answer to this question is directly related to the comfort level in benefits and access to doctors. PPO’s and POS will generally have the largest doctor networks, including national access, whereas HMO’s and EPO plans are more local in their coverage, HMO’s requiring referrals to see a specialist.

HMO’s for the most part are more “consumer friendly” in that general services and with the exception of hospitalizations are generally not subject to deductibles, including ER visits.

Golden Health Plans