Understanding the Jungle of Health Insurance Plans: HMO, PPO, EPO, POS
Friends, just imagine! You suddenly fall ill and the hospital expenses become so high that all your savings are exhausted. In such a situation, health insurance can prove to be a boon for you. But there are many types of health insurance plans available in the market, seeing which your mind can get confused. HMO, PPO, EPO, POS... what are all these and which plan will be best for you, this is a very difficult question.
In this article, we will help you get out of this jungle of health insurance plans. We will tell you how HMO, PPO, EPO and POS plans work, what are their advantages and disadvantages, so that you can choose the most suitable plan for yourself.
HMO (Health Maintenance Organization)
HMO means Health Maintenance Organization. It is a type of network that includes hospitals, doctors and other healthcare providers. Under the HMO plan, you can get treatment from only those doctors and hospitals that are included in this network. If you get treatment from a doctor outside the network, the insurance company usually does not bear its expenses.
Benefits of HMO plan:
- Low premium: The biggest feature of HMO plans is that their premium (insurance amount) is much lower than other plans. This is because the insurance company already fixes the rates of treatment with the doctors and hospitals of the network.
- Focus on Preventive Care: HMO plans put more emphasis on preventive care, that is, prevention from disease. Network doctors encourage you to get regular checkups, vaccinations and screening tests, which reduces the risk of diseases.
Disadvantages of HMO Plan:
- Limited Choice of Doctors: Under an HMO plan, you cannot go to the doctor of your choice. You have to get treatment from only those doctors who are included in the network.
- Referral Needed: If you need to go to a specialist doctor, you will have to get a referral from your primary care physician.
- Long Waiting Time: Sometimes, you may have to wait a long time to get an appointment or for treatment. This is because the doctors included in the network have a lot of patients.
Summary
HMO plan can be a good option for those with a low budget. If you are healthy and you do not need to go to the doctor regularly, then HMO can be beneficial for you. But if you need to get treatment for a specific disease or you want to go to the doctor of your choice, then HMO may not be suitable for you.
PPO (Preferred Provider Organization)
PPO means Preferred Provider Organization. This is also a type of network, which includes hospitals, doctors and other healthcare providers. But unlike HMO, in PPO plan you are allowed to get treatment from doctors outside the network as well. However, you will have to spend more if you get treatment outside the network.
Benefits of PPO Plan:
- More Choice of Doctors: In PPO plan, you have more freedom to go to the doctor of your choice. You can also get treatment from doctors outside the network, although you will have to spend more for this.
- No Referral Needed: In PPO plan, you do not need to take a referral to go to any specialist doctor. You can directly take an appointment with the specialist.
- Shorter Waiting Time: Since you are allowed to get treatment from doctors outside the network, you do not have to wait long to get an appointment or to get treatment.
Disadvantages of PPO plans:
- Higher Premium: The premium of PPO plans is higher than HMO plans. This is because the insurance company has to manage the expenses of doctors outside the network as well.
- Higher Out-of-Pocket Costs: If you get treatment from a doctor outside the network, you will have to pay more out-of-pocket. That is, you will have to pay more money from your pocket.
EPO (Exclusive Provider Organization)
EPO means Exclusive Provider Organization. It is a combination between HMO and PPO. In EPO plan, you are not allowed to get treatment from doctors outside the network. If you get treatment from a doctor outside the network, the insurance company does not bear the cost. But the premium of an EPO plan is higher than an HMO plan.
Advantages of EPO Plan:
- Lower Premium: The premium of an EPO plan is higher than an HMO plan, but lower than a PPO plan.
- No Need for Out-of-Network Care: In an EPO plan, you are not required to get treatment from doctors outside the network.
Disadvantages of EPO Plan:
- Limited Choice of Doctors: In an EPO plan, you have to get treatment from only those doctors who are included in the network.
- Referral Needed: In an EPO plan too, you will have to take a referral to go to a specialist doctor.
POS (Point of Service)
POS means Point of Service. This is also a combination between HMO and PPO. In a POS plan, you are allowed to get treatment from doctors outside the network, but you will have to spend more for this. The premium of a POS plan is higher than an HMO plan, but lower than a PPO plan.
Advantages of POS Plan:
- More Choice of Doctors: In a POS plan, you have more freedom to go to the doctor of your choice.
- No Referral Needed: In a POS plan, you do not need a referral to go to a specialist doctor.
- Lower Premium: The premium of a POS plan is lower than a PPO plan.
Disadvantages of POS Plan:
Higher Out-of-Pocket Costs: If you get treatment from a doctor outside the network, you will have to spend more out-of-pocket.
Tips for Choosing a Health Insurance Plan
Now that you know about HMO, PPO, EPO and POS plans, how do you choose the most suitable plan for you? Here are some tips that can help you choose the right plan:
Assess Your Needs: First, assess your needs. Do you need to visit the doctor often? Is there a member in your family suffering from a serious illness? Do you want to get treated by a particular hospital or doctor? The answers to these questions will help you choose the right plan.
Consider Your Budget: The premium of health insurance plans varies. Choose a plan that is affordable for you, keeping your budget in mind.
Be Mindful of Deductibles and Copays: Deductible is the amount that you have to pay every year from your own pocket, only after that the insurance company bears the cost of your treatment. Copay is the amount you have to pay for a doctor's visit or hospitalization. Keep these things in mind so that your out-of-pocket expenses are not too high.
Check the Coverage: Make sure your plan provides the coverage you need. For example, does the plan cover pre-existing illnesses? Does the plan cover mental health and substance abuse treatment?
Check the Insurance Company's Reputation: Check the reputation of the insurance company. You can read online reviews or talk to people about the insurance company.
Possibility of Changing Plans: Some insurance companies allow you to change plans once a year. Keep this in mind so that you can change plans according to your changing needs.
Summary
Choosing a health insurance plan is an important decision. Choose the right plan keeping in mind your budget, needs, and the reputation of the insurance company. This will keep you financially secure for sudden medical expenses.
What is Covered in a Health Insurance Plan?
So far we have told you about various health insurance plans. Now we will know what is included in a health insurance plan.
Generally, a health insurance plan includes the following things:
Inpatient Coverage: This coverage covers the cost of hospitalization, which includes surgery, doctor's fees, medicines, room rent, and other charges.
Outpatient Coverage: This coverage covers the cost of treatment without hospitalization, which includes doctor's fees, medicines, and tests.
Emergency Coverage: This coverage covers the cost of treatment in an emergency situation, such as an accident or sudden illness.
Preventive Care Coverage: This coverage covers the cost of regular checkups, vaccinations, and screening tests.
Mental Health and Substance Abuse Treatment Coverage: This coverage covers the cost of mental health and substance abuse treatment.
Dental Coverage: This coverage covers the cost of dental treatment, such as fillings, root canals, and dental braces.
Vision Coverage: This coverage covers the cost of eye exams and purchasing glasses or lenses.
Some health insurance plans may also include additional coverage, such as:
Ambulatory Surgery: This coverage covers the cost of surgery in a hospital on the same day.
Home Healthcare: This coverage covers the cost of getting treatment at home.
Travel Assistance: This coverage covers the cost of getting treatment in case of illness or accident while traveling.
Summary
A health insurance plan includes several types of coverage. Some of these coverages are included in all plans, while some coverages may vary depending on the plan. Keep these coverages in mind while choosing the plan that best suits you.
What is Not Covered in a Health Insurance Plan?
So far we have told you about what is included in a health insurance plan. But it is also important to know that some things are not covered in a health insurance plan.
Generally, the following things are not covered in a health insurance plan:
Experimental Treatments: If a treatment or medicine has not yet been fully tested, the insurance company does not bear its cost.
Cosmetic Surgery: The cost of plastic surgery or other aesthetic surgery is usually not covered in a health insurance plan, unless it is necessary due to an illness or injury.
Diseases Caused by Substance Abuse: If your disease is caused by substance abuse or drug abuse, the insurance company does not bear its cost. Injuries Caused by War or Terrorism: If your injury is caused by war or terrorism, the insurance company does not cover the cost.
Injuries Caused by Hazardous Activities: If you get injured by engaging in a health-hazardous activity, such as drinking alcohol while driving or playing dangerous sports, the insurance company does not cover the cost.
Some health insurance plans may also exclude additional items, such as:
Dental Appliances: Some plans do not cover the cost of dental appliances, such as brackets or dental implants.
Eye Surgeries: Some plans do not cover the cost of laser eye surgery or other eye operations.
Summary
Some items are not covered in a health insurance plan. These include experimental treatments, cosmetic surgery, illnesses caused by addiction or drugs, injuries caused by war or terrorism, and injuries caused by activities that are harmful to health. Keep these factors in mind while choosing the plan that best suits you.
