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Medicare Hmo Vs Ppo Plans
Everyone must have health insurance now that the Affordable Care Act is in effect, but that doesn’t make health care any less confusing. We tend to go with what we know or what we’ve always had when it comes to insurance, but the reality is that you have options.
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In California, health insurance plan options primarily include a health maintenance organization (HMO) and a preferred provider organization (PPO). There is a third option, the Exclusive Provider Organization (EPO), which is growing in popularity in California.
While all of these plans can provide the coverage you need, it’s important to understand each one individually and then compare them to each other. Not understanding the differences between HMO, PPO, and EPO plans can lead to significant unexpected costs and the disappointment of switching doctors due to a change in insurance. These plans offer coverage, but there are significant differences in how they work and how much they cost.
Whether you’re uninsured and looking to buy a plan soon, or you’re just exploring your options as a Californian, we’ve got you covered on HMOs, PPOs, EPOs, and Kaiser Permanente.
Of the three plan types — HMOs, PPOs, and EPOs — you have HMOs and PPOs at two opposite ends of the spectrum, with EPO plans somewhere in the middle. First, you need to recognize the difference between HMO and PPO plans. Then you can see where EPO fits in, as a hybrid of the other two.
Hmo Vs Ppo Vs Epo: Understanding Different Types Of Plans
HMO plans primarily revolve around primary care physicians (PCPs). Your PCP is the doctor you go to for annual checkups or when you’re sick. You can choose your own PCP, but they must be within the HMO’s local network of health care providers. Here are more specifics about HMOs:
But what happens when your PCP doesn’t think you need more treatment? Or that your condition does not require a visit to a specialist? These situations can happen and you should consider them. As long as you choose a PCP you trust, this probably won’t be a problem.
All of your health care is provided within your local network; if you see an out-of-network provider, you are responsible for paying out-of-pocket costs. If you have a doctor you like, are anticipating a change in insurance, and are considering an HMO plan, make sure your doctor is in the HMO plan’s network. If not, you will need to change doctors so that you have a PCP that is in your plan’s network.
There is an exception to the HMO network rule. You may be wondering: What if I’m on vacation and have an emergency? In this case:
Hmo Vs Ppo: Choosing Your Health Insurance
HMO networks are generally small, but there are two advantages to an HMO plan, both within the financial category. As you work in an HMO network, you will probably never have to make a claim. Instead, your insurance company works directly with your health care providers. Also, HMO plans almost always cost less – they typically have lower monthly premiums and lower out-of-pocket costs.
Yes, that means PPO plans, which are on the opposite end of the spectrum, are almost always more expensive, but with the added cost comes added flexibility and freedom. The network still exists, but you have the freedom to go to a provider outside your network if you want:
With a PPO plan, there is also more flexibility in choosing a PCP and seeing specialists. If you have a PPO plan, you are not required to have a PCP and can go to any provider you choose, but ultimately you will save money by choosing an online doctor.
You also do not need to have a referral from your PCP if you need to see a specialist; it’s a decision you can make without seeing your PCP first. You may even decide to see a specialist who is not in your network because you can with a PPO plan.
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With all this flexibility and freedom comes higher cost and a higher level of involvement in your health care, as you are often the one scheduling and coordinating the appointments, while the PCP takes care of most of that in an HMO plan. If you decide to see a doctor outside of your network, you may also need to gather information and submit a claim to your insurance company to receive a portion of the cost.
There are several critical differences between HMO and PPO plans, and there is no one-size-fits-all solution. Which one is best for you ultimately depends on your preferences.
There is a third option that is becoming increasingly popular in California: the Exclusive Provider Organization (EPO). This third option is sort of a hybrid of HMO and PPO plans. You’ll have many of the same freedoms you have with a PPO plan. Here is a list of features for the EPO plan:
Because you’re limited to using an exclusive network with an EPO plan, it’s usually less expensive than a PPO plan, making it a great compromise for those who want more control over their health care without paying significantly more insurance premiums. Again, you need to know if your doctor and any specialist you see is in-network, because you will be responsible for all costs if you see a doctor outside the EPO network.
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California is home to the nation’s oldest and largest HMO, Kaiser Permanente. Founded in 1945 and headquartered in Oakland, California, Kaiser Foundation Health Plan, Inc., an insurance provider serves people in California, Colorado, Georgia, Hawaii, Virginia, Maryland, Oregon, Washington and the District of Columbia.
The organization also supports Kaiser Foundation Hospitals and The Permanente Medical Group, Inc., a practice group of more than 9,000 physicians. Kaiser Permanente has created its own branded network.
As an HMO, Kaiser has a network of local providers in California that includes PCPs, laboratories, hospitals and pharmacies. If you live in a region where there isn’t a Kaiser facility, you can get care at places that Kaiser has a contract with—they don’t carry the Kaiser name, but are considered to be in the Kaiser network.
The Kaiser network currently serves more than eight million Californians through 15,774 physicians, 467 physician offices and 36 hospitals located throughout Northern and Southern California. You can view Kaiser locations through an online search.
Difference Between Hmo, Ppo & Epo Plans In California
You may have heard of Kaiser Permanente’s “Success” campaign. This wellness campaign emphasizes preventive care and includes 24/7 access to phone nurses, disease management programs, healthy lifestyle programs, and discounts on fitness classes and programs, among others.
In a way, Kaiser Permanente is taking HMO plans to a new level, literally having its physician groups and hospitals at the core, rather than being affiliated with different health systems. However, it’s still an HMO plan at its core, and thus comes with the limitations that define an HMO plan: You must stay in-network and manage all of your care by going to a PCP first.
The first step is to analyze your options; all three plans aren’t offered everywhere, so it’s best to start by looking at what’s available to you. You can start by entering simple information about yourself and your family, if applicable, on our website.
Requesting a free estimate will give you a list of options, including plan type (HMO, PPO, or EPO). Once you know what plans are available, you can start to consider your priorities.
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There is no winning plan, but a plan that will work best for you and your family. Consider how important each of these factors is:
When considering your options, remember that each of these types of insurance plans in California will provide you with the health services you need. The way they provide those services seems different. Individuals and families come in all shapes and sizes, and so do insurance plans.
Now that you have basic information about HMO, PPO, and EPO plans and an explanation of how Kaiser Permanente fits in, you’re ready to get an insurance quote. Whether you are uninsured and need coverage or want to shop, we have an online tool that gives you the opportunity to get free health insurance quotes right away. Not only will you have the opportunity to see everything
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