HMOs cover only care provided by doctors and hospitals inside the HMO’s network. HMOs offer a wide range of healthcare services through a network of providers who agree to supply services to members. With an HMO you’ll likely have coverage for a broader range of preventive healthcare services than you would through another type of plan. HMOs often require members to get a referral from their primary-care physician in order to see a specialist.
When you have a HMO plan, you’ll be required to choose a primary care physician (PCP). If you don’t choose one yourself, the HMO will assign you one.
You may not be required to pay a deductible before coverage starts and your co-payments will likely be minimal. You also typically won’t have to submit any of your own claims to the insurance company. However, keep in mind that you’ll likely have no coverage for services given by out-of-network providers or for services received without a proper referral from your PCP.
Is a HMO Plan Right for You?
Advantages of using a HMO:
You want a plan with lower premiums
You need preventive care services (checkups, immunizations)
Preferred Provider Organizations (PPOs)
Preferred Provider Organizations (PPOs) cover care provided both inside and outside the plan’s provider network. Members typically pay a higher percentage of the cost for out-of-network care.
Advantages of using a PPO:
Freedom to choose almost any medical facility or provider for your healthcare needs
Part of out-of-network claims are covered by your insurance company
No referrals needed to see a specialist
Exclusive Provider Organizations (EPOs)
Exclusive Provider Organizations (EPOs) are a lot like HMOs: They generally don’t cover care outside the plan’s provider network. Members, however, may not need a referral to see a specialist.
An EPO is a network of individual medical care providers, or groups of medical care providers which provide healthcare to the subscribers; subscribers are required to choose a primary care physician from within the network.
Advantages of using a EPO:
Significantly lower rates of medical services
Lower rates of increase in monthly premiums
Point of Service (POS)
A point-of-service plan (POS) is a type of managed care plan that is a combination of HMO and PPO plans. Like an HMO, participants choose an in-network physician to be their primary care provider. But like a PPO, patients may go outside of the provider network for health care services.
Advantages of using a POS
Not required to use network providers, as with HMO coverage.
No deductible when using network providers
Can go outside the POS network without first consulting your primary care physician
Out-of-pocket costs limited.
Here’s the bottom line: When choosing a plan, consider your budget, deciding how much you can pay in monthly premiums, and your household’s future health needs (and the amount of out-of-pocket costs you will have).
If you’re with an HMO, are you happy with your plan? Feel free to share your thoughts in the comments section below.