HMOs, PPOs, POS, EPOs…how qualified do you feel to communicate the differences between these types of plans to your employees?  Better yet, just how well do you think they understand what’s being explained to them about the different types of coverage come enrollment time?  Especially today when the lines that separate the different types of coverage are more blurry than ever.

Essentially, the type of plan your company offers determines what kind of access employees have to providers who are outside of the plan network.  Since definitions vary greatly from plan to plan and state to state, there’s still a lot of gray area.  But here’s the basic description of each type of plan:

  • Health Maintenance Organizations (HMOs) – These plans cover only care provided by doctors and hospitals inside that HMO’s specific network.  And even then most require members to have a referral from a primary care physician before a specialist visit is covered.
  • Preferred Provider Organizations (PPOs) – These offer coverage for providers inside and outside the network, although members generally pay a higher percentage of the cost for providers who are out-of-network.
  • Exclusive Provider Organizations (EPOs) – Much like HMOs, these little-known plans usually only cover in-network providers.  However, the need for a specialist referral may be waived.
  • Point of Service (POS) – These plans generally fall somewhere in between an HMO and PPO.  The referral for a specialist visit might still be necessary, but members may have the freedom to use out-of-network providers (and pay a higher percentage of the cost).

While those basic descriptions may help to narrow down the basic coverages offered by a specific plan, it’s still a good idea to thoroughly evaluate the options before choosing the one that’s right for you.  Ask yourself…

  • Does this plan offer out-of-network coverage?
  • If so, does that out-of-network spending count towards the member’s out-of-pocket maximum (because legally it doesn’t have to)?
  • Is a primary care physician needed to serve as a gatekeeper for referrals?
  • And finally, is your doctor in your plan?

These and other tips are outlined in a recent TLNT article.  You can read the full text here or contact us if we can help answer questions about your plan options.