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[Mz iMac]

HMO, EPO, PPO, OMG! How to navigate insurance plans

Jun 29, 1:07 PM (ET)

By TOM MURPHY

Hunting for the right health insurance plan outside the workplace used to involve a much lower risk of losing hair — from tearing it out in frustration.

If a shopper could get coverage, the chain of events was often straightforward: Pick a plan, see a doctor and then wait for the insurer to eat most of the bill for that visit. But rising health care costs and the Affordable Care Act are changing the health insurance market.

Now customers have to think harder about the alphabet soup of plan options they sift through. Some coverage offers lower monthly premiums or lower deductibles, but in exchange for limited doctor choices and big financial penalties for straying outside those options.

Here's how these plans work, and some things to look out for:

HOW DO YOU TELL THESE PLANS APART?
Two plans becoming more common are health maintenance organizations, known as HMOs, and exclusive provider organizations, known as EPOs. Both restrict customers to a specific network of doctors. But an HMO generally requires a primary care doctor to act as a gatekeeper. If you need a specialist, you have to see the primary care doctor first for a referral.

EPOs, which are growing especially fast, don't funnel patients through a primary care doctor like an HMO.

Both types of coverage generally have smaller networks than more traditional — and often more expensive — plans known as preferred provider organizations, or PPOs.

If you opt for an HMO or EPO but go out of the network for care, you may have to pay the entire bill. PPOs general pay at least some of the cost for out-of-network care.

WHAT'S MY BEST FIT?
It depends on your appetite for risk, your health, and how much you care about seeing the doctor you want.

You may find the lowest monthly cost, also known as a premium, from an HMO, but a primary care doctor will direct your care and sign off on who you get to see.

You may find the lowest deductible, the amount you have to pay before most coverage starts, at an EPO. And EPOs can be a good fit for someone who doesn't have an established relationship with a doctor.

PPOs are better for patients who already see a few doctors and want to stick with them.

Regardless of the plan design, customers should learn about a plan's provider network before signing up. Check to see how many specialists are in a network or whether it includes the biggest health care systems in the region.

I'M TRAVELING THIS SUMMER. WILL AN EPO OR HMO COVER EMERGENCY CARE I MAY NEED ON THE ROAD?
You'll have coverage if a shark attacks you at the beach or car accident sends you to the emergency room. However, coverage may be limited for less-intense emergencies like a raging case of poison ivy, or a sinus infection.

Instead of heading to an urgent care clinic and paying the full, $100-plus bill for that visit, check first to see what your plan offers. Your insurer may provide a remote medical option that connects you with a doctor or nurse practitioner via your smartphone or computer to get a diagnosis and prescription.

WHY ARE HMOs AND EPOs BECOMING MORE COMMON?
Insurers can no longer decline to cover someone based on their health, and they are more limited in how they can vary prices based on a patient's age. That leaves insurers fewer ways to keep their costs low, and they have responded by offering plans with fewer options.

Insurers use these smaller networks of doctors and hospitals to steer patients toward what they deem to be better care and to gain leverage in negotiating rates with those providers.

HMOs have been offered for years, but they are making a comeback after falling out of favor. They made up more than half of the 3,870 total health plans offered this year through the federal government's healthcare.gov website, which runs insurance exchanges in most states, according to the online insurance brokerage eHealth. EPOs accounted for only 9 percent, but they grew by 48 percent compared to last year.

ARTICLE LINK

[millieshops]

It's taken decades for Medicare to reach where it is today and it's still not perfect, just better than the alternatives for the most part.  IMO, Congress should have will and must continue to work on a plan that makes insurance available to the greatest number of citizens in the most reasonable way.

We will never all agree on how that plan should look (negotiations of anything usually mean both sides get some and both lose some), but we need a national plan.

[Tinkrbl44]

@Mz iMac

I looked at the article and see June 29 .... but what year?   HMO's have been around forever, so this looks like it may be a very old article.

[Mz iMac]

@Tinkrbl44

The article's year is 2016. 

Also the article specifically stated "HMOs have been offered for years, but they are making a comeback after falling out of favor."

[SahmIam]

Love me a PPO.

[hckynut]

@Mz iMac

Are all the paragraphs above the words: Article link your own words? If so, what will this Article Link tell me that you haven't already said?

hckynut(john)

[sunshine45]

PPOs only for me.

[Nuttmeg]

I like this site for up to date health care information http://kff.org/

[PINKdogWOOD]

PPO for sure - I'm in the process of talking to various carriers for a supplement to Medicare for DH who turns 65 in January.  What I learned so far a couple of days ago is that PPO offers in & out of network plans while HMOs do not (only in).

This whole process is time consuming and mind boggling.  Today in fact we have an appt with our current retirement group with whom I signed up with for insurance.  DH is on my retirement ins which ends/cuts DH off this December.  Lucky for him on turning 65 and ready for Medicare all at the same time.  We're clarifying some things in our appt to make certain we're understanding accurately his options.

Never heard of EPO either, don't know what this stands for.

[Mz iMac]

@hckynut

Article Link = Is the "live" link to the actual article I fonted.

Sorry for the confusion.