Health Insurance

Health Maintenance Organization (HMO):

HMOs offer access to primary care, emergency services, specialists, and hospitalization, typically at a lower cost than other plans. However, you’ll have less choice when it comes to healthcare providers. There are often no deductibles, just a small co-pay per office visit, usually between $10 and $25. With an HMO, you’ll choose one doctor from the network to serve as your primary care physician (PCP), who coordinates your care. If you need a specialist, you’ll need a referral from your PCP, and the specialist must also be within the HMO network; otherwise, you’ll pay out of pocket. HMOs may have their own medical facilities, or they may work with outside providers, known as Individual Practice Associations (IPAs).

Exclusive Provider Organization (EPO):

EPOs are similar to HMOs, relying on a contracted network of doctors, hospitals, and other providers. However, EPOs don’t require you to have a primary care physician, and you’re often allowed to see specialists within the network without needing a referral.

Point of Service (POS):

POS plans combine features of both HMOs and Fee-for-Service (FFS) plans. You’ll have a primary care physician (PCP) who makes referrals to other providers within the network. When you stay in-network, you’ll pay a small co-pay, generally around $10, with no deductible. If you go outside the network, you’ll have more out-of-pocket costs, such as a deductible (about $300 for an individual) and co-insurance (30 to 40 percent of the cost). While staying within the network saves money, POS plans give you flexibility to go outside if needed, though you’ll be responsible for the paperwork to get reimbursed.

Preferred Provider Organization (PPO):

PPOs are networks of doctors and hospitals that serve a specific group, such as employees of a particular company or members of an association. Unlike HMOs, PPO members don’t need referrals from a PCP and can choose providers outside the PPO network. In-network care is often fully reimbursed, while non-network care may be reimbursed at 80 percent, and there is usually a deductible for out-of-network services. A major benefit of PPOs is their cap on out-of-pocket expenses—once you reach this maximum, the insurance company covers 100 percent of policy benefits. This cap includes deductibles and co-insurance but does not include co-pays or monthly premiums.