Insurance

Understanding Managed Health Care Plans

HMO, PPO, POS, EPO: What's the Difference

Understanding Managed Health Care Plans

 

 

 

Health maintenance organization (HMO), preferred provider organization (PPO), point of service (POS), and exclusive provider organization (EPO) plans are all types of managed health care plans. Because of their similarities, picking one may be confusing.

However, each type of health insurance system offers different options for your medical and health services. The health insurance network or service providers associated with your plan can make a difference for you because it may limit which doctors you can visit, or where you can get service. Understanding how HMO, PPO, POS, or EPO plans differ will help you find the right kind of health care, get your medical claims paid, and avoid any surprises.

 

 

 

 

 

 

 

 

 

 

 

2)Types of Managed Health Care Plans

 

 

Managed health care plans are health insurance plans that have contracts with health care providers and medical facilities. These contracts allow you to pay a reduced cost for services. The providers and medical facilities are part of a network, and how much your plan covers depends on whether you stay in-network or seek services outside of the network.

Managed health care plans have become popular health insurance choices so you can better manage your health care costs. The type of managed plan you have will dictate how you obtain your medical services.

The main types of managed health care plans include:

  • Health maintenance organization (HMO)
  • Preferred provider organization (PPO)
  • Point of service (POS)
  • Exclusive provider organization (EPO)

Before picking one, compare how restrictive or flexible the networks they use are. Each network determines who you can get medical services from and how your medical claims work.

With changes in medical care and health care, plan sponsors look for ways to reduce costs for themselves and plan members. The tighter the network of providers, the more cost-efficient the plan. Being familiar with the options may help you find affordable health insurance.

There are several different types of health insurance or medical insurance plans. The differences may sometimes seem complicated and overwhelming. You may only focus on basic things like the deductible, coinsurance, or trying to understand the terms of the health insurance policy, but there’s more to it than that.

Knowing how your managed plan works will let you know how much flexibility your plan allows for medical services if you need to get medical care. If you are trying to decide whether you will insure yourself through an employer-sponsored health plan, or through a family member’s or partner’s health insurance plan, these details may help you make the decision. If you find that one plan is better than another, you can consider a health insurance waiver. You can also maximize your use of two plans by filing a health insurance claim with dual coverage health insurance.

 

 

 

 

3)How Managed Health Care Plans Work

 

 

Managed health care plans tend to be more cost-effective than traditional fee-for-service (FFS) or indemnity health insurance plans because they share the medical cost financial risks between members, their insurance plans, and members of the managed care network. Employers who sponsor a managed health insurance plan will pay part of the annual premium. Employees pay the additional cost, which is often less. For example, in 2022, the average annual premium for family coverage was $22,221, with the employer paying $16,253 and the employee paying $5,969 per year.

Managed health care plans differ from FFS or indemnity plans because members usually must select a “primary care physician” from the network of doctors provided by the plan sponsor. Being part of a network will provide plan members access to services from network health service providers at set rates reducing the costs of the plan.

 

 

 

 

4)Pros and Cons of Managed Health Care Plans

 

4-1)Pros

  • Members benefit from reduced rates and guaranteed access to health care services
  • Billing systems help make filing paperwork with in-network providers easier
  • Providers have a steady stream of patients and clients in the network

 

4-2)Cons

  • Less flexible than FFS or indemnity plans

4-3)Pros and Cons Explained

 

When you have a managed health care plan, you have guaranteed access to a network of health care providers. And as long as you visit one of the in-network doctors or specialists, you’ll benefit from reduced rates, compared to if you went out-of-network.

When you visit doctors in-network, there’s a billing system that helps make the paperwork and claims process easier. This could speed up the process, too.

Physicians and providers also benefit from managed health care plans because they are likely to see more patients who are in the network. That gives them a steady stream of clients and consistent work.

However, compared to indemnity or FFS plans, there is less flexibility because you’re required to go to an in-network doctor, or risk paying more (or all of the costs) to see another health care provider. You may also need a referral to visit a specialist.

5)HMO vs. PPO vs. POS vs. EPO

 

 

If you do think you want to sign up for a managed health care insurance plan, it’s important to know how each one compares to the others.

5-1)Health Maintenance Organization (HMO)

 

A health maintenance organization (HMO) provides a way to take care of all employees’ or members’ health care needs with reduced costs by negotiating with specific doctors, hospitals, and clinics. You must use these specific providers in order to access the reduced fees within the medical insurance plan. In an HMO plan, you have the least flexibility but will likely have the easiest claims experiences since the network takes care of putting in the claims for you.

5-2)Preferred Provider Organization (PPO)

 

A preferred provider organization (PPO) offers reduced costs if you use the network of physicians and providers. You can go to a provider that is out of network, but you’ll pay more.

5-3)Point of Service (POS)

 

With a point of service plan (POS), you typically pay less when you utilize providers that are in the network. With a POS plan, you are required to get a referral from your primary care physician before seeing a specialist.

5-4)Exclusive Provider Organization (EPO)

 

With an exclusive provider organization (EPO), you can choose from the providers within the network and do not have to work with a primary care physician. However, any service taken outside of the network may not be covered at all.

Plan Type Network Coverage & Restrictions Referrals Out-of-Pocket Costs 
HMO Must stay in-network, except for emergencies Typically required Low
PPO Flexible, but staying in-network will likely cost less May not be required High
EPO Must stay in-network, except for emergencies May not be required Higher than HMO, lower than PPO
POS  Flexible, but staying in-network will likely cost less Required Higher than HMO and EPO, lower than PPO

6)Comparing Costs Between HMO, PPO, POS, and EPO Health Care Plans

 

 

In 2022, employer-sponsored health insurance plans paid an average annual premium of $22,221, with an average employee contribution of $5,969 for family coverage, according to the Kaiser Family Foundation (KFF) 2022 Employer Health Benefits Survey. Single coverage cost an average annual premium of $1,299 per employee (across all plans). The Kaiser Family Foundation also found that 46% of the employees surveyed were enrolled in a PPO plan, 16% in an HMO, and 9% in a POS plan.

Of all the plans, HMOs tend to be the least expensive for family plan employee contribution, and one of the lowest options for single coverage employee contribution. According to the Kaiser Family Foundation survey, employees paid an annual premium of $5,254 for an HMO plan with family coverage in 2022.

The survey did not single out costs for EPOs, but the Kaiser Family Foundation defined EPO and HMO plans as a single HMO plan. EPOs can also be cost-efficient, as long as you stay in-network. If you get the services outside of the EPO network or member hospitals, you could pay the costs entirely out of pocket.

And even though they were the most popular plan in 2022, according to the Kaiser Family Foundation, PPO plans may be more expensive than other plan types because you’ll pay more out-of-pocket costs, such as a higher monthly premium. The survey found that employees paid an average annual premium of $1,389 for single coverage in 2022.

POS plans have the most flexibility, but that also makes them more expensive than HMOs and EPOs. These plans may off the greatest flexibility, but are also likely to be more costly due to the absence of pre-negotiated network member agreements. The Kaiser Family Foundation found that an employees with family coverage in 2022 paid an average annual premium of $7,512 for POS plans.

While you can choose a PPO, HMO, POS, EPO, or another type of plan, you’ll also want to consider how much you’ll pay in deductible. A high-deductible health plan (HDHP) could save you money in premium payments. The Kaiser Family Foundation survey found HDHPs were the most affordable in 2022 for family coverage, with average annual premiums costing $5,129.

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