Health Insurance 

Types of Health Coverage

 

Health Maintenance Organization (HMO)

HMO with Point-of-Service (HMO/POS)

Preferred Provider Organization (PPO)

Exclusive Provider Organization (EPO)

Fee-for-Service (FFS)

Network –              Is the network open or closed?

Closed – consumers must use network doctors, hospitals, and specialists except in limited circumstances such as emergencies.

Open – consumers may use in-network providers or out-of-network providers.

Open – consumers may use in-network providers or out-of-network providers.

Closed – consumers must use network doctors, hospitals, and specialists except in limited circumstances such as emergencies.

None – consumers may use any doctor, hospital, or specialist.

Limits                Are there limits on choice of doctors, hospitals, or specialists?

Typically require consumers to choose a primary care physician (PCP) from the HMO’s network. With some exceptions, consumers must obtain a referral before seeing other doctors in the network.

Typically require consumers to choose a PCP and obtain a referral before seeing other doctors in the network.

Many PPOs permit consumers to see any network doctor without a referral. Some PPOs require consumers to choose a PCP and obtain a referral before seeing other doctors in the network.

Some EPOs permit consumers to see any network doctor without a referral.

None.

Payments        How do the plans and consumers share costs?

Consumers pay designated copays for covered services when accessing the HMO network. Some HMOs require consumers to meet a deductible before paying for services. Consumers do not typically pay coinsurance.

Consumers pay designated copays for covered services when accessing the HMO network. Some HMOs require consumers to meet a deductible before paying for services.

Consumers typically pay a copay for covered services when accessing the PPO network. Consumers may also pay a percentage of the total cost of the service.

Consumers may pay copays or coinsurance for covered services when accessing the EPO network. Many EPO plans require consumers to meet a deductible before paying for services.

FFS plans partially pay for medical services. Consumers are responsible for coinsurance.

Balances –             Is the consumer responsible for remaining balances?

A network provider cannot bill a consumer for any remaining balance after the consumers meets their copay.

Consumers are responsible for any remaining balance when using out-of-network providers.

Consumers are responsible for any remaining balance when using out-of-network providers.

Consumers pay entire cost of out-of-network services.

Consumers are responsible for any remaining balance charged by the provider.

Incentives –        Is there an incentive to use network providers?

Out-of-network services are not covered in a closed network.

Typically reimburse a higher percentage of the cost when using in-network providers.

Typically reimburse a higher percentage of the cost when using in-network providers.

Out-of-network services are not covered in a closed network.

Not applicable.