When selecting a health plan, you will want to know about a few common NETWORK Types:
- PPO (Preferred Provider Organization):
- These plans do not require a Primary Care Provider and allow you to go to doctors outside of the Network.
- There may be different limits, and deductibles when using services that are considered “Out Of Network”
- One way to look at In vs Out of network, is that IN Network, means they have agreed to a certain amount that can be charged for given services.
- An example*: Let’s say a doctor typically charges $400 for an office visit. If they are In Network, then they may have agreed to Office visits at a different cost, say.. $200. in this case, the doctor agrees to only charge $200 for the office visit and the plan, after any applicable deductible, pays it’s share (example* $100) and you pay the balance (example* the other $100).
- If that doctor was not IN NETWORK, then the plan might just pay them the In Network amount (in the previous example, that was $100) and you pay the BALANCE (in this example* $400 billed – $100 paid by the plan = $300 balance).
- * Please know this example is only for helping in the understanding of the mechanics of fee negotiation, and is not representative of actual fees/charges
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- Important to know is that the cost “out of Network” can be higher, and be subject to a different “deductible” and coverage levels, including possibly higher Total Out Of Pocket Costs amounts.
- Why get a PPO? Gives you the freedom to go to any doctor who agrees to see you and accept your insurance. There is no need for a primary care doctor. You manage your healthcare.
EPO (Extended Provider Network): These plans are like the HMO except that they do not require a Primary Care Provider, BUT (Like an HMO) wil require you to seek your care within their Network of providers. Unless it is an emergency (or other allowed exception).
You would most likely be responsible for all the costs for services utilized outside of the network
Why get an EPO? If your Doctors are in the network, and you are willing to choose providers/specialists etc inside the network, then this could be a cost effective option for you. Advantage over HMO? You do not need to choose a Primary Care Doctor, and typically would not need a referal from one to get care from a specialist. You still manage your healthcare, but you are to use in network providers in doing so.
- HMO (Health Maintenance Organization): These plans typically require the use of a Primary Care Provider. Typically, they will refer you to the various specialist that are within the Network. Unless it is an emergency (or other allowed exception),
- You would most likely be responsible for all the costs for services utilized outside of the network.
Why get an HMO? If your Doctors are in the network, and you are willing to use providers/specialists etc inside the network, then this could be a cost effective option for you. Your Healthcare is “managed” by your Primary Care Doctor.