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- EPOs offer lower costs but have fewer choices
- You cannot go outside of the network with an EPO plan
- EPOs may be somewhat beneficial to people with a large financial reserve or who don’t put as much emphasis on their choice of health care services and providers
When you are looking for health insurance, it is important to understand the various types of insurance that are available so you can make an educated choice. It is also important to comprehend the difference between insurance types and service delivery models.
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What is a delivery model?
When we speak of delivery models in health insurance, we are referring to the way that your entire health care plan and services are carried out. This would include everything from primary doctors’ visits to follow-ups, exams, tests, and even prescription drugs. It takes into account the cost as well as the availability you have and accessibility to various doctors and health care providers.
In most cases, you will see that it is a matter of choice or cost, so you have to weigh these factors and decide which is most important to you in the end.
Four Types of Insurance Delivery Models
One of the things you should be aware of is what type of delivery model is involved in your policy. There are four basic types of medical delivery models.
HMOs (health maintenance organization) insurance plans use a specific network of doctors and health care providers that belong to the same network. The idea is for the providers within the network to work together to provide a sound medical insurance coverage for their members in return for loyalty to the group’s services.
With an HMO, you will have a primary care physician that you will have to go through to receive care. You will also need the primary care physician’s approval before you can seek a referral to other doctors or specialists. These types of plans are designed for people who have regular checkups and use preventive care primarily and who want cheaper premiums.
PPOs are also known as “preferred provider organization” plans. Under this plan, you and your family can see any in-network specialist without a referral.
Unlike HMOs, you are not required to have a primary care physician referral, so you have more choice in deciding whether you need a specialist or not.
There will be copayments for non-preventive medical care, like an HMO. In some cases, there is an annual deductible under a PPO plan.
An EPO (known as an Exclusive Provider Organization)allows you to have access to all providers with the EPO network. However, you will not be allowed to go outside your network. You do not have to have a primary care physicians with this type of service model.
A POS (Point of Service) plan is a mix of HMOs and PPOs that allows you to designate a primary care physician for regular check-ups and referrals to other doctors. But you have the option of going outside your network if you are willing to pay more. There is usually a copayment and deductible.
POS plans are a good idea for people who like the freedom of choice and don’t mind paying for the privilege of going outside the network.
More About EPO Health Plans
Since this post is about EPOs primarily, we will focus on that form of insurance here. An EPO (Exclusive Provider Organization) plan lets you use any of the providers within the EPO network. This allows people who have trouble getting insurance that allows them to afford care to have a regular physician who knows their case and can advise them on what they should do regarding their ongoing health care.
But what if you want to go outside the network? The answer is: that you will not be able to do so. That is why EPOs are not highly regarded by many insurance customers.
In fact, since 2014, the popularly if EPOs has decreased. They have been widely replaced by POS plans, which allow you to go outside your network if you are willing to pay the difference.
Why Choice is Important in Health Insurance
The option to choose is important to many people when it comes to their health care plans. This is especially true if young children are involved. You may want to keep your child’s doctor if you have used this doctor for a long period so the most flexible programs allow you to go outside the network (which may include the doctor you are currently using).
Cost is Important Too
While choice is important to many people when it comes to their health care plan, there are many people who choose to go with doctors that are assigned to them within a network rather than pay the rising costs of some of the other plans.
Keep in mind, however, that the delivery model is not all that should be considered. You also have to filter this through your individual insurance company and see how they will deliver that type of insurance with the framework of their company and policies to get the full picture.
Money or Choice?
It all comes down to a matter of choice over money. In other words, if you want a cheaper delivery model for your health plan, you should choose an HMO or an EPO, which give you lower prices. But in exchange for the lower price, you get less choice. You cannot go out of the network without paying higher prices.
With an EPO, you have even less choice, though the price will be relatively small as well. EPOs are the most restrictive type of insurance because you cannot go outside the network at all. Any expenses that you incur from outside the network will be money that must come from your pocket.
For people who enjoy the lower costs involved with an EPO, they may be upset to discover down the road that they are going to have pay “out of pocket” if they find that they need to go outside of the network to get the best medical care. EPOs limit the ability to go outside the system at all, which is likely why their popularity is diminishing lately with a majority of enlightened consumers.
EPOs: The Limited Choice Model
EPOs have their place if you want cheap insurance. But when you have a family or others that you are also putting under this type of plan, you should carefully consider whether you are willing to have your health care plan dictate by the people in the network with your EPO. You will have very limited choice with this type of plan.
How to Choose the Best Plan
It can be confusing when you think about all of the various factors affecting your cost of health insurance as well as the different details that affect the way the types of health care work. It is also quite important to understand them since it involves something that affects something as important as your family’s health.
The best thing to do when you are deciding on a medical insurance plan is to consider what is important to you. Below is a list of factors that you may want to use to make your decision. Consider all of these issues one at a time and then think about how they may affect you and your family with your health insurance plans.
– Price and Budget
When it comes to health insurance, the price is always at the top of the list. One reason for this is the fact that health insurance is so expensive, to begin with. Doctors’ fees, hospital care, tests, and other expenses all add up to huge financial strain if you are hit with these expenses all at once. Even people who are “well off” may struggle to hang onto their savings in the event of a catastrophic event.
– Current Health Conditions
If you have pre-existing conditions, you will need to consider this as well. Some plans do not accept people with pre-existing health conditions. Also, such conditions may require referrals to specialists and other treatments. So you may want to have a higher degree of control over your health care services. In that case, you would want to use either a PPO or POS plan, in most cases.
– Number of Plan Members
One factor that may determine which plan you choose is the number of people who will be on the plan. If you are putting other family members on the plan as well, then you will also have to consider their health conditions and how much control you need to have over their health care, as well as the price.
– Age from Medicare Eligibility
If you are close to the age of 65, this means that you will qualify for Medicare once you reach 65. You should also know that once you receive Medicare, you will also be eligible to receive benefits with Medicare Plan D (prescription drug coverage). You must be a part of an HMO plan to receive these extra benefits.
– Amount of Prescriptions
– Financial Status
Another factor that should influence the type of plan you choose is your current financial status. If you have large savings, you are safer in choosing a higher-priced plan, and you will also have the option of choosing a physician that is out of network. If you choose an EPO but have an HSA (Health Savings Account), you might feel more confident in choosing this type as well.
The Pros and Cons of EPOs
When it comes to EPOs, lower prices are the primary advantage, while a loss of personal freedom and choice is the downside. If you want to have more freedom in your health care plan, you should choose either an HMO or PPO, which both allow you to go outside your network for a price, or a POS, which also allows you to find a doctor or specialist outside of your health insurance provider’s network.
EPOs are a type of insurance that many seek out due to the lower cost, but many end up finding their way back to the other plans due to the total lack of freedom regarding their health care options. This is especially true if they have other people on the plan or desire more choice in choosing their physician or need outside referrals to specialists or other health care providers.
It’s Your Choice
Remember that, when it comes to your health care, it is your choice! Obamacare (backed by the Affordable Care Act of 2010), is on the way out. As of this writing on January 13, 2017, Congress met today to abolish the first part of this plan, as it is now considered a plan that failed in its attempt to meet the needs of “all Americans.”
The truth about insurance (as well as anything else) is that there is no ‘cookie-cutter’ pattern. There is magic bullet or plan that fits all needs of everyone. In fact, health insurance, like many things, is a very personal thing that only the individual can decide what is needed.
No one knows your health care needs like you do. So you have the right to shop and compare prices and service options until you find a plan that is right for you.
We built this site because we believe that the individual is what health care is about. Taking care of your individual health needs (and the needs of your family) is something that you should have the ultimate choice with.
For this reason, on this site, we are never proponents of one type of insurance or another. We only report the facts about the different types of insurance as we know them from reliable sources. Then you can feel free to shop and compare and come to your conclusions about which one is best for you.
Shop and compare
This site was designed for you to look into the different health insurance companies, plans, policies, and service delivery models. It was designed with the individual in mind, as well as groups who are looking for a better insurance plan or who need to add onto their current coverage.
With something as important as health care, you can’t be too careful in the type of plan you choose. You usually are locked in for at least a year with the plan that you choose, so shop and compare well before making your final decision.
There are plenty of well-trained insurances specialists who can help you out when it comes to something as important as choosing your health insurance plan.
How to Choose a Company
We have talked a lot in this post about how to choose a health care delivery model. But we should also mention the importance of choosing the right company. Different companies will have different types of service models. Many will offer a variety of policies that features different types. So you should ask this when you call the companies to compare rates and policies.
Also, be sure to research your company that you are considering carefully so that you will know how they do business.
A good insurance company should always be open to questions from their customers, should pay claims promptly, and should be open to questions that you may have about your policy at any time.
Another way to check out the integrity or record of a company is to visit the Better Business Bureau to see what their rating is. This organization has been a source of checks and balances for many types of businesses over the years, and it continues to serve as an excellent resource when researching the credibility of the company.
Summary on Health Insurance
Is an EPO right for you or do you need another type? Think about your situation, your health conditions, and anything else that is relevant to you and make sure and share that when you get your free quote. The more information the representative has about your situation, the more likely they are to be able to help you design a plan to fit your needs.
Find the right health insurance type and plan for you by entering your zip code below and comparing free quotes!
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