Health Insurance

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Health Plan Basics ¹

The term “health plan” refers to both a health insurance policy sold by an insurance company and to an evidence of coverage sold by a health maintenance organization (HMO). Both types of health plans are commonly called “comprehensive” or “major medical” coverage. They cover a defined set of health care services and help you pay for medically necessary care.

Health plans won’t pay for noncovered services, so it’s important that you understand exactly what your plan covers. Also make sure you understand the costs you will be responsible for paying yourself, such as a deductible, copays, and coinsurance. Carefully review the Summary of Benefits and Coverage that comes with your health plan.

Health Maintenance Organizations

HMOs reduce costs by using networks of doctors and hospitals to provide their members’ care. An HMO will usually only pay if you use doctors and hospitals in its network. There are exceptions for medical emergencies and for medically necessary services that aren’t available in the HMO’s network.

You must choose a doctor from the HMO’s network to oversee all of your health care. This doctor is called your primary care physician. You must get a referral from your primary care physician if you want to see a specialist. Some HMOs offer a point-of-service option that gives you more flexibility to choose your doctors. You will still be required to choose a primary care physician, but you may go to out-of-network doctors without a referral. However, if you use doctors and hospitals that aren’t in your HMO’s network, you’ll have to pay more out-of-pocket for your health care. A point-of-service plan may exclude the option for out-of-network care for some medical conditions. Point-of-service coverage is usually offered as an add-on to the plan – called a rider – for an additional fee.

Preferred Provider Benefit Plans

A preferred provider benefit plan (PPO) is a network health plan offered by an insurance company. Although you can usually go to any doctor you choose, your out-of-pocket costs will be lower if you use doctors in the PPO’s network.

Doctors and hospitals in the network have agreed to charge a discounted price for services to the PPO’s members. Out-of-network doctors and hospitals haven’t agreed to the discounted prices and often charge more than what your PPO plan will pay for your care. You’ll usually have to pay this extra amount yourself. In addition, you’ll probably have to pay a separate deductible and higher copayments and coinsurance for any care you received outside of the network.

Exclusive Provider Benefit Plans

Exclusive provider benefit plans (EPO) plans are similar to PPOs. They negotiate agreements with doctors and hospitals to provide care to their members at a discounted rate. You must use doctors and hospitals in the EPO’s network. The primary difference between EPOs and PPOs is that PPOs will typically pay some of the cost of your care if you go to doctors or hospitals outside of their networks. EPOs will not. There are exceptions for medical emergencies and for medically necessary services that are only available outside the EPO network.