Health insurance plans generally utilize one of three provider network designs: PPO, HMO or POS. Knowing which one your plan uses helps you understand the extent of coverage your health insurance provides and plan for the bills following any services you seek. Fortunately, the differences can be summed up by asking two questions: 1: Will the plan provide out-of-network coverage? and 2: Does the plan require the oversight of a primary care physician?
With a Preferred Provider Organization (PPO) network design, you are free to see any provider you want. You will pay a smaller portion of the bill if you seek services from an “in-network” provider, which is a provider that participates in the health plan’s preferred network. If you seek services from an “out-of-network” provider, however, you will pay a larger portion of the bill. An “out-of-network” provider is one that does not participate in the health plan’s preferred network. PPO plans may have access to out-of-state providers, and it’s best to contact the carrier to locate out-of-state providers whose services will be classified as in-network.
If your plan features a Health Maintenance Organization (HMO) network, you will first choose a primary care physician (PCP) within the HMO who will coordinate your healthcare. When you require diagnostic services or the services of a specialist, HMO plans may require a referral from your PCP, but not all HMO plans require this so make sure you ask. When you receive services from a provider outside the HMO network or without a required referral from your PCP, you will most likely pay for the full cost of those services. HMO networks for group health insurance plans may provide some access to out-of-state non-urgent/non-emergency care, but that can vary.
Point of Service (POS, or sometimes labelled HMO-POS) plans are a hybrid of PPO and HMO network designs. Like an HMO, you choose a PCP, and referrals may be required for the plan to cover visits to a specialist or diagnostic testing. Like a PPO, you will pay a smaller portion of the bill if you use in-network providers and a larger portion of the bill if you use out-of-network providers. A POS plan is best described as an HMO plan with reduced coverage (as opposed to no coverage) for services provided by out-of-network providers. Out-of-state coverage varies depending on the insurance carrier.
Other provider network designs exist (like EPO, Choice, Narrow, etc.), and all of them feature to some degree the characteristics of PPO and HMO designs. Keep in mind that urgent and emergency services throughout the United States are almost always covered to some extent regardless of provider and network design. For coverage outside the United States, it is a good idea to check with your health insurance carrier well in advance of any foreign travel. Of course, the best idea is to ask the expert agents at Ieuter Insurance. We will be happy to explain how your health plan works!
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