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

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 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.

Published: Wed, Jul 06, 2016


  1. No comments
Sign in to post a comment »