HMO/EPO, but no PPO in CO
People shopping for individual health insurance for the first time are often surprised at the amount of work it takes to get insurance and what benefits are available. (By “individual health insurance” I mean a plan that is not provided by an employer or the government and is available to individuals under 65 years of age when Medicare becomes an option.)
“I would like a PPO” is a common request from people trying to find individual health insurance. This is often followed by “I want to be able to see any doctor and go to any hospital.” Companies offering individual insurance plans try to offer the lowest possible premiums to attract customers, while also having sufficient revenue to meet Affordable Care Act (ACA) requirements. These include covering pre-existing conditions, no benefit maximums, and covering the 10 essential health benefits.
One way to control costs is by creating a specific doctor and hospital network of providers who negotiate reimbursement rates with the company. The insurance company offers more potential patients for the doctor, while the provider offers reimbursement discounts and more of that doctor’s patients signing up for the insurance. When they reach an agreement, that doctor or hospital is put on the insurance plan’s approved provider list. The traditional meaning of Preferred Provider Organization (PPO) is a plan that covers any doctor, but gives the client a lower out of pocket cost for going to doctors in the “preferred provider” network. This is also called having “out of network benefits”.
Several years ago, insurance companies stopped offering a PPO plan for the individual market in Colorado—both on the state’s health benefit exchange called Connect for Health Colorado and purchased directly from insurance companies. This left clients with EPO plans or HMO plans:
· Exclusive Provider Organization (EPO) means the plan requires members to get coverage from a doctor or hospital in the plan’s network.
· Health Maintenance Organization (HMO) means the plan requires using in-network providers only (like the EPO), but also means the insurance company takes a more active role in managing the care of its members.
· Emergencies. Regardless of these network restrictions, all ACA-compliant plans must cover emergency room benefits anywhere in the US in the same way they would cover an in-network emergency room.
Network restrictions are most problematic if you have one or more doctors who you strongly want to continue seeing, or you have a condition that could require very specialized care not covered by the insurance. There are practical and insurance strategies that can address some issues clients face in managing their care. If you have questions or concerns about these issues, let’s talk.