What is the difference between epo pos and ppo

If you're willing to pay a higher monthly premium to get more choice and flexibility in choosing your physician and health care options, you may want to choose a PPO health plan. An EPO, or Exclusive Provider Organization , is a type of health plan that offers a local network of doctors and hospitals for you to choose from. Each time you seek medical care, you can choose your doctor.

You have the choice between an in-network and out-of-network doctor. When you visit an in-network doctor, you get in-network coverage and will have lower out-of-pocket costs.

In an emergency 1 , your care is covered. Requests for non-emergency hospital stays other than maternity stays must be approved in advance or pre-certified. This allows Cigna to determine if the services are covered by your plan. Pre-certification is not required for maternity stays of 48 hours for vaginal deliveries or 96 hours for caesarean sections.

Out-of-network care is allowed in emergency cases only. This PCP is your main health care contact. Your care is often coordinated through them. You may even need to get a referral from them to see a specialist. You may need to get advanced approval before having certain medical services performed, but in an HMO, in many cases that preapproval will be handled through your PCP, if you have one. PCP stands for primary care physician or provider.

In a network, this is usually a doctor who practices internal medicine, family or general practice, or pediatrics. This PCP coordinates the majority of your medical care in the network, handling physicals, routine illnesses, preventive care and so on. Your PCP will also arrange referrals to specialists or preapprovals for certain medical services when needed.

Want to see someone in-network? Want to see someone out-of-network? Premiums tend to be higher with this type of plan, which is commonly often paired with a deductible. Here are more details about PPO plans:. Similar to an EPO, a PPO network is made up of those doctors and facilities that have negotiated lower rates on the services they perform. PPO health plans have access to those negotiated rates.

You may have lower out-of-pocket costs from the PPO provider than you would out-of-network. However, PPOs do vary, so be sure to check the network requirements before you apply. Almost every network requires preapprovals for some medical services, and in a PPO, because you have more freedom to choose where to go and who to see, you may face more preapprovals. In some networks, preapprovals are required for some services or procedures. Without preapproval, that service may be covered less or not at all.

Preapprovals are sometimes called prior authorizations. Those are acronyms for the different types of managed care plans available in most areas. Start with basic definitions of the types of health plans. HMOs offered by employers often have lower cost-sharing requirements i. PPOs have lost some of their popularity in recent years as health plans reduce the size of their provider networks and increasingly switch to EPOs and HMOs in an effort to control costs.

But in some states, PPOs have disappeared altogether in the individual insurance market individual insurance is the kind you buy on your own—including through the exchange in your state—as opposed to obtaining from an employer. EPOs got that name because they have a network of providers they use exclusively. However, an EPO generally won't make you get a referral from a primary care healthcare provider in order to visit a specialist. For reference, non-managed care plans are called indemnity plans.

These are health plans that don't have provider networks, and simply reimburse a portion of your charges for any covered medical service. Medical fixed indemnity plans are considered excepted benefits under the Affordable Care Act, and are not subject to its regulations; coverage under a fixed indemnity plan is not considered minimum essential coverage. Note that another frequently-used acronym, HSA , does not refer to a type of managed care.

HSA-qualified plans must meet specific plan design requirements laid out by the IRS, but they are not restricted in terms of the type of managed care they use. In order to choose the best type of health plan for your situation, you need to understand the six important ways health plans can differ and how each of these will impact you.

But there are no hard-and-fast rules, and the lines between the different types of managed care plans can blur quite a bit. Some types of health insurance require you to have a primary care physician. In these plans, the PCP is your main healthcare provider who also coordinates all of your other healthcare services.

For example, your PCP coordinates services you need like physical therapy or home oxygen. He or she also coordinates the care you receive from specialists. Because your PCP decides whether or not you need to see a specialist or have a specific type of healthcare service or test, in these plans your PCP acts as a gatekeeper controlling your access to specialty healthcare services. In plans without a PCP requirement, getting access to specialty services may be less of a hassle, but you have more responsibility for coordinating your care.

Generally, health plans that require you to have a PCP also require you to have a referral from your PCP before you see a specialist or get any other type of non-emergency healthcare service.

Drawbacks to this requirement include delays in seeing a specialist and the possibility of disagreeing with your PCP about whether or not you need to see a specialist. In addition, the patient may have additional costs due to the copay required for the PCP visit as well as the specialist visit.

Although it's typical for HMO and POS plans to have referral requirements, some managed care plans that have traditionally required PCP referrals have switched to an "open access" model that allows members to see specialists within the plan's network without a referral. And as we saw above, some EPO plans do require referrals, even though that's not the norm for that type of plan. So although there are generalities about managed care plans, there's no substitute for reading the fine print on your own plan or the plans you're considering.

In plans that require you to have a PCP, that physician is primarily responsible for making sure you really need the services you're getting. Plans that don't require a PCP including most EPOs and PPO plans use preauthorization as a mechanism to reach the same goal: the health plan only pays for care that's medically necessary. Plans differ as to what types of services must be preauthorized but almost universally require that non-emergency hospital admissions and surgeries be pre-authorized. Many also require pre-authorization for things like magnetic resonance imaging MRI or computerized tomography CT scans, expensive prescription drugs, and medical equipment such as home oxygen and hospital beds.

If in doubt, call your insurance company before you schedule a medical procedure, to see if a pre-authorization is necessary. Pre-authorization sometimes happens quickly and you'll have the authorization before you even leave the healthcare provider's office. More often, it takes a few days. In some cases, it can take weeks.

This network includes doctors, hospitals, labs, and other healthcare providers that either have a contract with the health plan or, in some cases, are employed by the health plan. The exception to this is emergency care. Managed-care plans will cover emergency care received in an out-of-network emergency room as long as the health plan agrees that the care was truly necessary and constituted an emergency. Note that the out-of-network emergency providers can still bill you for the difference between what they charge and what your insurer pays, and this can leave you on the hook for a significant amount of money.

In other plans, the insurer will pay for out-of-network care. Regardless of the plan design, out-of-network providers are not bound by any contracts with your health insurance company.

Even if your POS or PPO insurance pays a portion of the cost, the medical provider can bill you for the difference between their regular charges and what your insurance pays. If they do, you're responsible for paying it. Managed health insurance plans are a way for health plans to control costs. Fee-for-service and indemnity health insurance plans are other types of plans, but those usually cost more for employers. Managed health insurance plans pool members and create provider networks.

Those providers follow contracts with health insurance companies. That includes payment levels and even offering a certain level of quality rather than fee-for-service.

With managed care, health insurance companies can better control costs and providers are rewarded for reducing patient health care services by offering high-quality care. Employer-sponsored health insurance is how most pre-retirement people get health insurance. You can also sign up for an individual or family plan through the Affordable Care Act ACA marketplace or a similar plan directly from a health insurance company.

Other health insurance options are Medicare and Medicaid if you qualify. Eligibility for those plans is connected to your age Medicare and household income Medicaid. Get Quotes. Written by: Les Masterson Les Masterson has more than 20 years of writing, editing and content creation experience.

Get Quotes or call Which health insurance plan is best for you? HMOs have a stronghold in the individual market, while HDHPs offer lower-cost options for those with employer-based healthcare. PPOs are the most popular type of health insurance plan given that they offer more flexibility to the employees.

POS is great if you want more choice over the options provided by your insurer, while those that don't mind having less options in doctors and facilities may prefer EPO.

What is an HMO? What is an HDHP? What is a POS? What is an EPO? Choose the Right Health Insurance Plan for you and your family Our Health Insurance Finder tool helps you explore your health insurance options so you can find the health plan that fits your needs.