- Mangrum Agency
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- July 25, 2022
PPO – EPO – HMO Provider Networks
Every Health Insurance Plan is served by some type of Provider Network. This can greatly affect the quality of Healthcare Coverage that is available to you. The primary concern is: Who is in my Network?
PPO or Preferred Provider Network: This is the broadest network available. There are more providers in a PPO than in the other types of networks. A PPO does not require a referral and will generally provide coverage if you go out of network. Out of network coverage normally has higher copays/coinsurance. Bear in mind that most specialists require a referral even though the insurance doesn’t. Hospitalizations and outpatient procedures can be subject to preauthorization.
EPO or Exclusive Provider Network is very similar to an HMO, but it does not require referrals to go see a specialist. You are restricted to a network of providers. If you go outside of the Network, except for emergencies, you will not have any coverage. It is imperative to make sure that your doctors participate in the EPO or you will have to change doctors. Hospitalizations and outpatient procedures require preauthorization.
HMO or Health Maintenance Organization is the most restrictive type of Provider Network. You must select a Primary Care Physician (PCP) who will direct your healthcare. The PCP must give a referral to see a specialist and all procedures and hospitalizations require preauthorization. Emergencies are the exception, but be careful as the carrier is the one who will determine if something is an emergency. All care must be done within network or there will be no coverage. One positive side to HMO’s is that their focus is to keep you healthy and generally cover more maintenance procedures at no charge.
Another offshoot of HMO is the HMO-POS or Health Maintenance Organization-Point of Service. This network is an HMO but will allow you to go outside of network if your network cannot provide the needed treatment.
When you choose a Health Plan, make sure you understand what type of Provider Network the Plan has and who participates in the network.
If you have questions about your Health Plan, contact me by phone: (817) 554-2233; email: firstname.lastname@example.org.