Health Insurance Plans

Types of Health Insurance Plans

HMO: Health Maintenance Organization Plan

In an HMO, you can receive services from the healthcare providers within the plan’s network. First, you will need to choose a Primary Care Provider (PCP). The PCP will provide you with the services you need. If you need care which your PCP cannot provide s/he will refer you to a specialist within the network. If you need to see a specialist who is not within the approved network of providers, you will usually need to pay 100% of the cost of seeing the out-of-network doctor. Thus, when choosing an HMO plan, be sure that their network of accepted care providers include the doctors you think you may need in the future.

An HMO is right for you if: you want lower out-of-pocket cost, less paperwork, and the doctors you wish to see are in the HMO network.

PPO : Preferred Provider Organization Plan

In a PPO, there is a network of approved providers but you do not need to choose a PCP (primary care provider). You do not need to get a referral to see a specialist. You can visit care providers inside or outside of the plan’s network. However, if you do see a doctor/specialist outside of the network, your out-of-pocket costs will be higher. Even if you see a doctors within the plan’s network, you will usually need to make a co-payment or a percentage of the cost of the visit.

An PPO is right for you if: you want the flexibility of seeing any care provider without the need for a referral and you don’t mind paying a little more out of pocket for everyday health services.

EPO : Exclusive Provider Organization Plan

A EPO is similar to a PPO: you don’t need to get a Primary Care Provider, you don’t need to get referrals to see a specialist, and you don’t have to stay within your plan’s network of care providers. However, if you choose a doctor outside of the network, you will need to pay 100% for the cost of service. If you choose a provider within the network, your out-of-pocket is a bit lower than that of the PPO.

An EPO is right for you if: you want the flexibility of seeing any care provider without the need for a referral. If you work within the network, your everyday cost is a bit lower but the cost is high if you go outside of the network.

POS : Point of Service Plan

A POS takes elements from the HMO and PPO plans. Like an HMO, you will need to choose a PCP who will care for your health needs and provide a referral to a specialist if you need one. However, like a PPO, you can use a provider inside or outside of the plan’s network. If you use a doctor outside of the network, you will pay more, but not 100% (as in the case with HMO). Equally important: you will need to pay for the services upfront and then submit the paperwork to the insurance company to be reimbursed.

An POS is right for you if: you want the flexibility of seeing a care provider outside of your network, you have the money to pay upfront, and you don’t mind doing the paperwork to get reimbursed.

More Insurance Plans

In addition to HMO, PPO, EPO, and POS, there are more types of health care plans such as:
  – High Deductible Health Plan
  – Indemnity Health Plan
  – HSA-Qualified Health Insurance Plans
  – Catastrophic insurance plans
Please ask your insurance provider for more information.

Tiered Plans

Be aware that some health care plans are tiered, this means that care providers are placed into different tiers or categories. Patients are encouraged to see doctors in the most cost-effective tiers. Some doctors or specialists may be in your network but they are in a tier which will cost more. For example, you may need to pay $25 to see a doctor in tier 1, $35 for a doctor in tier 2, or $45 for a doctor in tier 3. Be sure to read the fine print before you choose a health insurance plan.


Emergency Care

Most insurance plans will have allowances for emergency care services even if it is outside of the network because emergencies can happen anywhere and at anytime. However, these services will only be covered if it is a true emergency situation. Do not go to the emergency room for routine care or vaccinations. Emergency care services are costly and insurance providers will only cover the costs if it is a true emergency.



 


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Associates in Family Medicine
5222 Balboa Avenue, Suite 31
Clairemont

San Diego, CA 92117
Phone: 858-565-6394
Fax: 858-999-2006
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858-565-6394