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HMO, PPO, and EPO. What Is The Difference?

by | Dec 21, 2024

HMO, PPO, or EPO – Which One Is Best For Me?

You’ve probably heard the terms HMO, PPO, and EPO. We created a simple side-by-side chart that shows the basic features of HMOs, PPOs and EPOs. Please note, there is no right or wrong choice when it comes to selecting your health insurance plan, it’s more of a preference, not a wrong or right choice. Do you prefer to eat an apple or banana? It’s a preference. Having a clear understanding of these plans and how they work will help you in choosing the plan that’s best for you, your family, and your budget.

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HMO, PPO, and EPO. What Is The Difference?Pin

What is a PPO?

PPO stands for Preferred Provider Organization. A PPO health insurance plan allows for more flexibility and more choices when it comes to your healthcare. It offers a network of healthcare providers to choose from and you have the freedom to receive care from within that network or choose an out-of-network doctor, specialist, or hospital, without a referral. Keep in mind, however, that your out-of-pocket medical costs are lower when you choose an in-network provider but overall, out-of-pocket costs are higher with PPO Plans.

Flexibility

PPO plans do not require you to choose a Primary Care Physician (PCP) and do not require referrals. Let’s say you have a doctor or specialist that you like and have been seeing for years. With a PPO plan you could continue your visits whether they are in-network or out-of-network and without the need for a referral. If your PPO plan has a nationwide network of doctors, you can go anywhere in the USA. Check your plan details for more info.

It is important to remember that while you can receive care from any doctor, specialist, or hospital you choose, you will save more money by choosing an in-network provider.

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Higher Monthly Premium

(and hard to find since the ACA was passed)

The greater flexibility of a PPO often comes with a higher monthly premium, co-pays, and other costs too. While you can choose to use doctors, specialists, or hospitals outside of your network, finding health plans that are PPO in Nevada have been in short supply since the passage of the ACA. Please call us for the latest on availability of PPO Plans in Nevada. We have several EPO plans now available that work like PPO Plans.

What is an HMO?

HMO stands for Health Maintenance Organization. With an HMO plan, you must choose a Primary Care Physician (PCP) from a network of local healthcare providers who will refer you to in-network specialists or hospitals when necessary. All your care is coordinated through that PCP. HMO plans won’t cover out-of-network care except in an emergency.

 

Lower Cost

With an HMO plan, your out-of-pocket medical costs and monthly premiums will generally be lower than a PPO.​

 

Selecting a Primary Care Physician (PCP)

With an HMO plan, you’ll select a Primary Care Physician who will be your contact for all your healthcare, and they will connect you to specialists or other health care providers.

 
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A summary of benefits (SBC) is a 4-page document explaining a health insurance plan’s coverage, costs, and examples. It helps compare plans, understand costs like premiums and deductibles, and assess coverage for services like doctor visits or preventive care. Available through Nevada Health Link, the SBC is standardized for easy comparison but does not include provider networks or full exclusions. Learn how to use the SBC to choose a plan that fits your needs.

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What is an EPO?

EPO stands for “Exclusive Provider Organization.” An EPO is a type of health insurance plan that offers a local network of doctors, specialists, and hospitals in your area for you to choose from. These plans are among the most affordable options with generally low monthly rates and many of the plans contain co-pays before the deductible.

 

 

 

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EPO Health Insurance Plans: Understanding Your Options

It’s important to note that those with an EPO plan have health insurance coverage only for in-network doctors and hospitals, and there are no out-of-network benefits (except for emergencies). For that reason, an EPO health insurance plan may be well-suited for those whose doctor is either part of their plan’s network or for those who don’t mind switching to another doctor. It may also be for those who enjoy the idea of not having to get a referral to see a specialist. Keep in mind, however, you’d have to stay within the EPO’s network.

 

Is an EPO Health Insurance Plan Right for You?

If you’re considering an EPO plan, it’s important that you carefully read the coverage terms and fine print of the plan. EPO health insurance plans are an attractive option for many because they have relatively lower monthly premiums.

In general, EPO plans may be a good option for those who want the freedom to schedule appointments directly with specialists and don’t mind the possibility of switching to a healthcare provider that is covered by their network. If the specialist requires you to get a referral, that is the doctors preference, not a requirement of your insurance plan. Look for plans that have more “1st dollar benefits” meaning, co-pays BEFORE the deductible. Not all plans are built the same. Some EPO plans will have a higher deductible but give you lower co-pays. Some will have lower deductibles and give you higher co-pays.

Some EPO plans may have HSA (Health Savings Account) plans, which are health insurance plans where you can open a separate bank account and place money into this account using pre-tax dollars to pay your medical expenses with. These plans, however, generally do not have any co-pays until the deductible has been met, but do offer tax savings if used correctly.

 

Nevada Insurance Enrollment Can Help

Unfortunately, insurance company’s use a variety of coverage terms that are often riddled with industry verbiage that can be difficult to decipher. At Nevada Insurance Enrollment, our health insurance agents specialize in helping our members understand their options. To learn more about HMO, PPO, or EPO plans or to apply for health insurance, contact one of our licensed agents today

What is a Summary of Benefits and Why Should I Read It?

A summary of benefits (SBC) is a 4-page document explaining a health insurance plan’s coverage, costs, and examples. It helps compare plans, understand costs like premiums and deductibles, and assess coverage for services like doctor visits or preventive care. Available through Nevada Health Link, the SBC is standardized for easy comparison but does not include provider networks or full exclusions. Learn how to use the SBC to choose a plan that fits your needs.

Nevada Insurance Requirements for Vehicle Registration

Confused about insurance requirements for vehicle registration in Nevada? Learn why auto insurance is mandatory, with minimum liability coverage of 25/50/20. Understand how to provide proof, navigate the registration process, and avoid costly lapses. From required documents to penalties, this guide covers it all. Discover optional coverages and cost-saving tips to stay protected.

What Is a Health Insurance Carrier?

A health insurance carrier provides plans to cover medical expenses, like doctor visits and prescription medications. Understanding your insurer’s network, plan types (HMO, PPO), and costs (premiums, deductibles) is key to choosing coverage. In Nevada, carriers collaborate with Nevada Health Link to offer ACA-compliant plans, ensuring access to preventive care and essential benefits. Learn how to select a dependable health insurance company and manage costs effectively.

What is a Prescription Drug Deductible?

In the world of health insurance, “deductible” is a common word. It refers to an amount of money that you pay out of your pocket before the insurance company begins to pay. A prescription deductible is the portion you’d pay first, then after you’ve paid the deductible, you may only have to pay a co-pay when you pick up your medication.

If you are single, you would only have to meet your prescription deductible. If you have two or more people in your family, each member may have to meet their own prescription deductible which could be up to 2 deductibles in the family. A prescription deductible is different and separate from the medical deductible, unless otherwise stated. One deductible is for medical, ie: hospitalization, doctors, etc., and the other deductible is for filling your prescriptions.

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