HMOs * PPOs * POSs * EPOs
Many types of health plans differ in
* how freely you can choose your doctor, hospital, or other
* to what extent the plan manages utilization of the medical services
* how much of the costs the plan pays and how much you pay.
Indemnity plans are the traditional form of health insurance.
There are no restrictions on which doctor, hospital, or other provider you
may see. Typically, the insurer pays the provider directly, or in some cases,
pays you first and you pay the provider. Most indemnity plans cover a specific
percentage of customary and reasonable expenses after a deductible. You are
responsible for the balance.
A Preferred Provider Organization (PPO) plan encourages you to
choose doctors, hospitals, and other providers that participate in the plan.
They do this by increasing the portion of the bill they pay if you stay "in
network." You may choose to go "out-of-network" at any time, but if you do,
youll have to pay a higher percentage of the providers bill.
Other than physician office visits and emergency care, services must usually
be authorized by the PPO before you receive them. Some PPOs have a primary
care physician who is responsible for coordinating your medical care. PPO:
(Preferred Provider Organization). A PPO is a Preferred Provider Organization.
In simple terms, a Preferred Provider Organization is a group of providers
who have come together, and negotiate their rates for treatment with various
health plans. These PPO organizations have been around for a long time, and
vary in size depending upon where an employer or employee is located throughout
the country. There are several national PPO organizations, but there are
also many local or regional PPO organizations. Regional or local PPO's tend
to provide better rates, and more extensive provider coverage, than national
organizations. The PPO provider that your plan utilizes is important, because
ultimately, if dictates the cost of claims to the plan, and future cost to
you and the employer. From an employee prospective, the PPO is also important,
as it dictates where the employee will get care, and how easy access to that
care will be. It is important to select carefully a PPO, based not only upon
cost, but also on provider access, and quality of organizations that are
part of the PPO.
An Exclusive Provider Organization (EPO) plan is very similar
to an HMO. With an EPO, you must select a primary care physician or physician
gatekeeper who will be responsible for meeting your health care needs. In
most EPO plans, as with an HMO, if you choose to go out-of- network, you'll
have to pay 100% of the provider's bills. EPO: (Exclusive Provider Organization).
An EPO is an Exclusive Provider Organization. In simple terms, an EPO is
a much smaller PPO, offering a very limited number of providers, who offer
deeper discounts on their rates, because they will see a higher volume of
patients. This type of organization is becoming more popular, as it is a
good middle ground between an HMO and PPO. EPO's can be set up in many different
ways. The most cost effective are those that are a "Closed Panel". "Closed
Panel" means an individual must select an EPO Provider to get care. Very
much like an HMO, a Primary Care Physician will direct all care for the
individual within the EPO. The EPO's physicians still provide high quality
care based upon the financial incentives built into the program. In choosing
an EPO, it is important to make sure that the program includes enough providers
to match your employees' needs, and also offers contracts that have some
flexibility. Exclusive Provider Organizations (EPOs) are similar to PPOs,
but only reimburse members for services rendered by providers in their network.
A PPO may also make an EPO option available to payers.
Point of Service (POS) plan. This is a variation of the HMO and
EPO plans and is often described as an open-ended HMO. As with an HMO, you
must pick a primary care physician within the network. You pay least when
you receive services from your PCP or through an authorized referral to another
provider. But unlike an HMO, you may opt out of the network. If you opt out
you'll be responsible for paying a portion of the provider's bills.
Foundations for Medical Care (FMCs) are physician organizations
established by county or state medical societies. FMCs operate similarly
to IPAs, in that they comprise physicians practicing individually or in single
specialty groups. The forerunners to IPAs, FMCs provide physician and hospital
services to employers. During the past few years, some FMCs have also developed
HMOs, IPAs, UROs or PPOs; some operate predominantly as PPOs.
Health Care Financing Administration (HCFA): part of the U.S.
Department of Health and Human Services, HCFA administers Medicare and
A Health Maintenance Organization (HMO)
plan requires that you select a primary care physician (PCP) within the HMO
provider network. Your PCP is responsible for meeting your health care needs,
either by taking care of you directly or by referring you to other providers
(such as specialists). As long as you see your PCP or have an authorized
referral to another provider, your out-of-pocket cost is usually a relatively
small copayment per visit. But if you chose to go to another provider without
a referral--whether or not the providers are in the HMO network--you'll have
to pay 100% of the provider's bills. The exceptions are true emergency situations
for which you are covered by the plan. Health Maintenance Organizations (HMOs)
are health delivery systems that offer comprehensive health coverage for
hospital and physician services for a prepaid, fixed fee. HMOs contract with
or directly employ participating health care providers--i.e., hospitals,
physicians, and other health professionals--and HMO members choose from among
those providers for all health care services. HMO's are one of the most popular,
and fastest growing forms of health care coverage in the country. There are
many types of HMO's.
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