Tag Archives: epo

PPO, HMO, EPO

Obamacare 2016

Today more than ever, people need help when buying insurance.  Some say they want Obamacare, some say they don’t want Obamacare.  Here is the skinny on Obamacare.

Plan Benefits

Obamacare is not an actual plan.  Obama made the laws and it has been coined “Obamacare”, but you still get the insurance directly from the insurance companies, however if you buy it ON EXCHANGE through healthcare.gov then you may qualify for a subsidy or a reduced premium.  In addition, when you buy on the exchange you have a longer time to pay your premiums than if you buy OFF EXCHANGE.  Therefore, THAT is why a lot of the doctors are not taking Obamacare/ON EXCHANGE plans because in theory, you could use the 3 month grace period to pay your premiums and still get care during that time.  The doctors could get stuck with treating you and never getting paid by the insurance company, or getting paid 3 mos later.  THAT is why they don’t want to take it.  Problem is, most of the companies sell the same plans ON and OFF EXCHANGE so the doctors have no idea if the person has 3 mos extra to pay or not — so they are all saying we won’t take any insurance!!!  Can you see what is going on now?

The benefits of the plans are still great, the problem this year is who will take the insurance you buy.  So make sure you look up your doctor to see if they are in network or not.

Networks

This year the networks are the key to everything.  Instead of shopping benefits, you are essentially shopping networks of providers.  A lot of companies have done away with offering PPOs entirely and are only offering EPOs and HMOs.  Again, there is nothing wrong with the benefits of either of these plans, in fact the benefits of an HMO are typically better than a PPO, however you are restricted to a certain network of doctors and those doctors are not the doctors you have seen for 20+ years.  The reason for that is, on an HMO the doctors in essence get paid less each time they see a patient than if they were to file the claim through a PPO.  In addition, there is a whole lot more paperwork to keep up with when filing a claim on an HMO too.  So a lot of the doctors who have been in business for a long time, don’t want to change how they do things (with good reason).  Therefore, the result is, you have newer “hungrier” doctors on the HMO networks.  The doctors possibly fresh out of medical school or the ones still trying to build their practice.  This doesn’t make them bad doctors, again, just not the doctors you have seen for 20+ years.

Changes

So because of all the changes within the Affordable Care Act, ACA for short, a lot of doctors are getting out of the practice.  This year, you will probably have to change doctors and will have to pay more for your insurance so be prepared.  If you decide to go without insurance entirely, there is a penalty, and it did increase for 2016.  Be aware of all of your options, and it is still FREE to have an agent help you.  They are still the most knowledgeable resources available.

What is a PPO HMO POS EPO

Is it an acronym city or the abbreviations you put behind your name! Health insurance plans are categorized by a few main ways: PPO, HMO, POS, and EPO.

Depending on which plan you buy, depends on if your care is covered when you see a network provider or any doctor. In addition, you may have larger deductible or coinsurance, and/or you may have to get a referral if you want to see a provider out of network

PPO (Preferred Provider Organizations)

PPOs give you the choice of seeing providers in network or out-of-network. You pay less if you use in network providers. You’ll pay more if you want to go out of network for doctors, providers, and hospitals. You may have higher out-of-pocket costs too. If you have a PPO plan, you can visit any doctor without a referral.

POS (Point-of-Service)

POS plans let you go to both in-network and out-of-network providers. With a POS plan, you will have to choose a PCP or primary care doctor from a list of participating providers in network. Your PCP will refer you to other in network providers as needed. If you choose to go to an out-of-network provider, you’ll need a referral and you may pay higher out-of-pocket costs.

HMO (Health Maintenance Organizations)

HMO plans usually require you to seek care from in network providers who work for or contract with the HMO. An HMO generally doesn’t cover or has limited coverage if you go out-of-network except in an emergency. If you choose to see a doctor or facility that isn’t in the HMO network, you may have to pay the full cost. Like the POS plans, HMO members usually have a PCP and must get a referral to see a specialist.

EPO (Exclusive Provider Organizations)

EPOs are much like the HMO in that they generally have coverage only if you see a provider in the EPO network (except in an emergency). Health plans generally can’t require higher copayments or coinsurance if you get emergency care from an out-of-network hospital, no matter what type of plan you have. However, providers may bill you for some additional costs.