Types of Insurance

EPO (Exclusive Provider Organization)

EPO's are among the most popular types of health insurance, and function much like a PPO with a much lower cost. This lower cost is possible because EPO's limit coverage to in-network providers or facilities. Like a PPO, you may select where you access and receive care; from general practitioners, to specialists, to outpatient facilities. Copayments and deductibles are similar to those found in PPO plans (even in-network coinsurance or cost-sharing amounts), but there is no out-of-network coverage. The insured is fully responsible for costs of care delivered by an out-of-network provider. Except for sudden and serious emergency situations, out-of-network coverage is not an option under an EPO plan model. It is always best to understand emergency out-of-network coverage under an EPO plan so you are prepared to make decisions if the situation presents itself. When considering an EPO, be sure to check the provider network to ensure it will meet your needs. Most plans offer comprehensive medical coverage in-network, but may limit coverage and services to a specified geographic area. Under most carriers, prescription coverage and plan riders will be the same or very similar to those offered under PPO's or even HMO's. EPO plans can be a sensible option for those seeking the coverage and freedom of a PPO, but are willing to sacrifice the ability to seek care outside the provider network in return for a lower premium.

HMO (Health Maintenance Organization):

HMO models are in-network-only designs that utilize significant managed care policies that oversee and control access to care and services. They don't carry nearly as many freedoms as a PPO model does, but will be available at a much lower monthly cost (among the lowest). HMOs also don't normally carry any deductibles or coinsurance amounts (portions of the expenses under PPO and POS models that are shared by subscribers) HMO plans will commonly require the selection of a Primary Care Physician (PCP) who is responsible for managing your healthcare needs –both for you and the insurance carrier. Access to specialists, testing, out-patient hospital procedures and more is all provided through referrals from your PCP. There are no covered out-of-network providers, services, or facilities under an HMO plan; all care must be accessed within the network for plan benefits to apply. Sometime out-of-network services are unavoidable and subscribers must be prepared (or at least aware) to bear the potential costs. Some HMO models contain healthcare facilities –medical buildings that literally contain just about any services you may require for general care, lab & diagnostics, prescriptions, physical therapy, and more. For some this "one-stop-shopping" facility can be just the right fit for some individuals and families. HMOs, while containing limits, can be an advantageous and prudent choice depending on your individual healthcare needs.

PPO (Preferred Provider Organization):

A PPO Plan model is one of three most often discussed healthcare delivery systems. The initials, PPO, refer to the provider network type and the care management system. A PPO plan is one that allows free movement both within and outside of the plan's participating provider network. The network can include general practitioners, specialists, labs, diagnostic facilities, outpatient or free-standing facilities, hospitals, durable medical equipment, pharmacies, opticians, holistic/alternative providers, therapists and more. "Free movement" within the network is commonly referred to as referral-free access (or self-referral) to doctors, specialists and more. Other plan models will require the selection of a Primary Care Physician (PCP) who is then responsible for assessing your care needs and making the appropriate referrals for additional care. However, in a referral-free PPO model some hospital admissions, diagnostic testing, out-patient surgery and more will require pre-certification. This is a process of advising the insurance carrier of your intentions to have certain services rendered and essentially receiving their approval to do so. This ensures the services received will be covered under your plan benefits as the plan allows. The main feature of a PPO plan model is the ability to access care and services outside of the plan's network. PPO plans will cover a percentage or portion of your out-of-network care according to their allowable charges schedule (note that "100% coverage" means 100% of the plan's allowable charges; not 100% of the total bill). PPO plan models will traditionally have out-of-network care deductibles and coinsurance amounts (portions of the expenses that are shared by subscribers) that must be met before or in conjunction with applicable plan benefits. PPO plans tend to be the most expensive plans to purchase because of their lack of their "freedoms" in accessing seeking and obtaining care.

POS (Point of Service):

A POS plan model is somewhat of a hybrid of the PPO and HMO models. A POS plan will require the selection of a Primary Care Physician (PCP), who functions as your point of service "care manager" and determines what steps or referrals should be made for the course of your care. Under a POS model, the PCP can refer patients to both and in and out-of-network providers (like a PPO, be sure to understand what your out-of-network benefits will provide for), but referrals are required as part of the managed care aspect of the POS model. Like a PPO, POS plans traditionally contain deductibles and coinsurance amounts (portions of the expenses that are shared by subscribers) that apply to out-of-network services. Monthly POS plan costs will fall somewhere in between the HMO and PPO models because although there is PPO-like freedom to seek care inside or outside the plan network, there are managed care limitations like an HMO.

Fee-for-Service:

Most often used in conjunction with "Discounted Fee-for-Service"; as the term relates to discounted benefit programs. Differing from insurance plans where one might pay only a copay at the time service is rendered or submit a claim to the insurance carrier for reimbursement, a Discounted Fee-for-Service indicates an applied discount for services where payment-in-full is expected at the time the services are rendered. Discounts on "discount fee-for-service" benefits can range anywhere from 5% to 60% and are most often applied to vision, dental, prescriptions, limited-medical in-network services, hearing and equipment programs, and more. A discounted-fee-for-service allows the consumer to realize the benefit without having to take any further action (other than pay the discounted price) or submit any additional paperwork; such as a claim form.

Managed Care

Managed care is a generic term for various health care payment systems that attempt to contain costs by controlling the type and level of services provided. Health maintenance organizations (HMOs) most often utilize and are associated with managed care/managed care practices. HMOs are a type of managed care organization.

The primary intent of managed care is to reduce health care costs. Emphasis is placed on preventive care and early intervention, rather than acute/critical care provided after an illness or injury has occurred (much more costly treatments and services). The responsibility of limiting services is often shared by the doctor/provider and the plan subscriber. Subscribers are normally required to pre-certify certain procedures, treatments, and/or costs before they can be declared as "covered" by the insurance carrier. "Gatekeeper" or Primary Care Physician policies require that individuals get referrals for specialized treatment from their primary physicians selected at the time of enrollment (changes to one's PCP can usually be made at any time). Network providers are normally issued guidelines for administering care, prescriptions, testing and more—all designed to help limit excessive and potentially unnecessary or costs. Most every claim and most care plans (submitted by Primary Care Physicians) are also reviewed by the managed care organization first before the organization will deem the services and related expenses as "covered."

Dental

Dental coverage comes in many forms. The most commonly found designs are Discounted Fee-for-Service, Dental Maintenance Organization (DMO), and Dental Preferred Provider Organization (PPO). All are designed to provide lower-cost dental services to a large group of insureds or members by directing them to a participating network of dentists through which fees for specific, predetermined services are negotiated at a reduced price. In the Discounted Fee-for-Service model, available dental services are listed along with their discounted prices. One must visit a network dentist to receive these discounted prices and should expect to pay for the services when rendered. These plans are traditionally the least expensive plan type.

Under a Dental Maintenance Organization (DMO), services are available on an "in-network" basis only. Payment for services can be in the form of a copay or co-insurance payment (co-insurance payments are usually much higher than a copay as they make up a larger portion of the service cost). No coverage is offered for services provided by
dentists outside of the DMO network. These plans are going to be priced to be affordable and fall in a "mid-range" category.

A Dental PPO model will allow for both "in-network" services as well as "out-of-network" services. In-network services are usually covered at a higher level with less subscriber out-of-pocket costs, while out-of-network services are covered at lower levels and can require the subscriber to bear a greater portion of the cost. Dental PPO plans are the most expensive plan type of the three because of the level and range of benefits provided.

A Dental DMO or PPO plan model will traditionally carry annual benefits maximums anywhere between $750 - $2,500 per policy or calendar year. Discounted Fee-for-Service models ordinarily do not have limitations on how much or how often you utilize the network discounts.