Health Insurance Terms Explained: HMO, EPO and PPO Plans (2024)

FAQs

What is the difference between an HMO and a PPO and EPO insurance? ›

EPOS (exclusive provider organizations) combine features of HMOs and PPOs. They have exclusive networks like HMOs do, which means they are usually less expensive than PPOs. But as with PPOs, you'll be able to make your own appointments with specialists. Want to get started with Covered California?

EPO Cons. Out-of-network care is not covered: Out-of-network care is not covered under EPO plans, except for emergency care. If you want to see a doctor that is not in-network, you have to pay the full medical bill.

Doctors often prefer PPOs because they offer greater reimbursem*nt rates compared to HMOs and have less administrative paperwork. Is a PPO a good thing? For many, a PPO's flexibility and coverage make it a favorable choice, but it comes with higher premiums.

HMO plans typically have lower monthly premiums. You can also expect to pay less out of pocket. PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral.

EPO and PPO plans are both solid options that can help cover medical costs for you and your family. If you're looking for coverage that reaches beyond a limited network, then a PPO may be right for you. However, EPOs tend to be more affordable and offer sufficient coverage for in-network medical services.

A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan's network (except in an emergency).

By injecting EPO, athletes aim to increase the number of red blood cells and, consequently, their aerobic capacity. If EPO levels are too high the body will produce too many red blood cells which can thicken the blood, leading to clotting, heart attack and stroke.

EPO is used mostly to relieve the itchiness caused by skin conditions, such as eczema and dermatitis. It is also used to ease breast tenderness from premenstrual syndrome (PMS) or other causes, and to help manage menopausal symptoms.

HMO plans might involve more bureaucracy and can limit doctors' ability to practice medicine as they see fit due to stricter guidelines on treatment protocols. So just as with patients, providers who prefer a greater degree of flexibility tend to prefer PPO plans.

What are three disadvantages of HMO? ›

Out-of-Network Coverage: HMOs generally provide limited or no coverage for out-of-network services, except in emergencies. If individuals need to seek care outside the network, they may face higher costs and reduced coverage, which can be a disadvantage for those who prefer greater flexibility in choosing providers.

One of the biggest advantages of PPO policies is their flexibility. Given that PPO plans offer a larger network of doctors and hospitals, you have a lot of say in where and from whom you get your care. Any doctor and healthcare facility within your insurance company's network offers the same in-network price.

Coinsurance is an insured individual's share of the costs of a covered expense (it usually applies to health-care insurance). It is expressed as a percentage. If you have a "30% coinsurance" policy, it means that, when you have a medical bill, you are responsible for 30% of it.

There are times when certain tests and screenings aren't considered preventive care. Things like diagnostic care, bloodwork and sexually transmitted infection (STI) testing may or may not be considered preventive.

PPO health insurance allows you more freedom to get care anywhere, while a POS plan may allow out-of-network care but demand a primary care referral. A PPO health insurance plan doesn't typically require that you name a primary care provider to oversee your care.

“A POS plan is a hybrid of HMO and PPO plans,” explains Orefice. Like with an HMO, your in-network physician must be your PCP.

An HMO is a health maintenance organization. The Department of Managed Health Care (DMHC) oversees all HMOs in California and some other kinds of health plans. An HMO is a kind of health insurance that has a list of providers, such as doctors, medical groups, hospitals, and labs.

Preferred provider organization (PPO) A type of medical plan in which coverage is provided to participants through a network of selected health care providers, such as hospitals and physicians. Enrollees may seek care outside the network but pay a greater percentage of the cost of coverage than within the network.