The major types of health plans include:
- Health Maintenance Organization (HMO) - This type of policy is the most restrictive kind of health insurance. One physician or nurse practitioner is designated to serve as your primary care doctor, and that person provides most of your medical care, including referring you to specialists and other health care professionals as needed. Insurance coverage is not available if you elect to see a specialist without a referral from your primary care doctor.
- Preferred Provider Organization (PPO) - This type of policy places some restrictions on where you obtain health care. A PPO plan offers a limited number of doctors and hospitals to choose from, although it is broader than a typical HMO. When you use those in-network providers, a greater share of your medical bills will be covered. When you use an out-of-network provider, you may receive some insurance coverage, but will have much higher costs.
- Point of Service (POS) - This type of plan is closely related to an HMO. In a POS plan, you may access specialists and obtain other medical services without a referral, but your financial liability will be greater than when you obtain a referral and see a network provider.
- Exclusive Provider Organization (EPO): Similar to an HMO, with an EPO you must use network providers - doctors, hospitals and other health care providers - that participate in the plan. The only exception is for emergency care. Unlike an HMO, you do not need to select a Primary Care Physician, nor do you need to contact your PCP for referrals to specialists. However, because you are responsible for choosing specialists and hospitals, it is especially important to check with the plan by phone or their website to be sure the provider is in the network
- Indemnity - There are few restrictions on what providers you can see, and there is little involvement from the health insurance company in managing your care. Traditional indemnity plans (also called "fee for service") insurance, where patients chose their own doctors, pay for their care, and receive reimbursement by their insurance company for some or all of their doctor's bills are not commonly sold and usually include substantial cost sharing.
|Plan Type||Is there a limited provider network?||Is a primary care physician (PCP) required?||Are specialist referrals required?|
(Health Maintenance Organization)
(Preferred Provider Organization)
|Not usually, but your cost exposure could be very high out of network||Not usually||
|Typically has an in-network and out-of-network benefit plan||Yes, for maximum coverage levels||
Yes, for maximum coverage levels
EPO (Exclusive Provider Organization)