For health insurance, there are different network plans that affect who you can see in-network and who share the costs of your plan. These plans are available at all different metal level types and can be found in the marketplace in a wide range. These include an Exclusive Provider Organization (EPO), Preferred Provider Organization (PPO), Health Maintenance Organization (HMO), and Point of Service (POS) plan. All of these plans vary based on network requirements and cost-sharing functions. Here are some brief descriptions below:
Exclusive Provider Organization (EPO):
With this plan, services are only covered if they are obtained within network—meaning, obtained from doctors and other medical specialists who work with the plan’s insurance. Services obtained out-of-network, with exceptions for emergency situations, are not covered. The plan works exclusively with in-network providers (hence the name).
Preferred Provider Organization (PPO):
If you use providers that are within the plan’s network, you pay less than if you use out-of-network providers. While you can use out-of-network providers and you will be covered, you will have to pay more and your care will have an additional cost added to it. If you are obtaining services from out-of-network providers based on a referral from an in-network provider, you will likely not have that additional cost tacked onto your care (though, for the most part, referrals tend to be amount in-network providers).
Health Maintenance Organization (HMO):
With this plan, coverage is limited to doctors who contract with or are employed by the HMO. To be eligible for coverage under an HMO, you might have to live in the area in which the plan provider operates—in the “service area.” HMOs will generally not cover out-of-network visits to doctors not contracted with or employed by the HMO unless in an emergency situation. A unique feature of HMOs is their focus on preventative and integrated care and wellness in providing health services to their members.
Point of Service (POS):
With this plan, you will pay less if you use doctors within the network. In order to see a specialist, you have to get a referral from your primary care physician. While you can visit providers out of network, you will have to pay out-of-pocket for a large portion of that care.