Are you confused with all of the jargon health insurance companies use?
During this time, many of the employers we partner with have aIf you’ve ever looked over the different plans, you’ve probably been inundated with acronyms like EPO, HMO, and so on.
Eden Health simplifies the overly complex, often overbooked, and rigid We will define and cover the differences between EPO vs. HMO to help you better understand these options.
What is HMO Insurance?
Before we uncover the differences between EPO vs. HMO health insurance, let’s first take a look at what each one offers.
A health maintenance organization (HMO) restricts member coverage to medical care supplied by a contracted network of doctors and other healthcare providers. HMOs charge a monthly or yearly premium for health insurance coverage.
Because health providers benefit from having people steered to them, premiums for these contracts are cheaper than for standard health insurance. They also impose additional limitations on HMO members.
When choosing between EPO vs. HMO insurance plans, consider the cost of premiums, out-of-pocket expenditures, any personal medical issues you may have, and whether having your primary care provider (PCP) is essential to you.
An HMO is a formally established public or private institution that offers primary and additional health care to its members. Contracts with PCPs, clinical facilities, and medical specialists help businesses ensure their network of health providers is robust enough to attend to any medical condition. Medical practitioners and centers that sign contracts with the HMO are compensated for providing various services to the HMO’s customers. Because of the agreed-upon payment, an HMO may charge cheaper rates than other forms of health insurance while still offering superb care from its network.
HMO members pay a monthly or yearly fee to access medical services provided by the organization’s network of doctors. Still, they are limited to receiving treatment and services from doctors in the HMO’s network. With that being said, some out-of-network services, such as emergency care and dialysis, may be covered by the HMO.
To be eligible for coverage under an HMO, you may need to reside or work in the plan’s network region.
If a subscriber requires emergency treatment while traveling outside of the HMO’s network territory, the HMO may reimburse the costs. Non-emergency, out-of-network treatment, on the other hand, must be paid for out of pocket by HMO members.
An HMO often has low or no deductibles in conjunction with inexpensive rates. Instead, the organization charges a co-pay for each clinical visit, test, or medication. HMO co-pays are often minimal ($5, $10, or $20 per treatment), lowering out-of-pocket costs and making HMO plans more reasonable for families and businesses.
What Are Some of the Benefits of HMOs?
- Reduced out-of-pocket expenses, such as cheaper premiums, lower or no deductibles, and fewer co-pays.
- As your primary care physician oversees your care, you’ll likely receive a higher standard of care.
What Are the Disadvantages of HMOs?
- Before the plan pays out, you must meet several requirements.
- A referral from your primary care physician is required to see a specialist.
What Is EPO Insurance?
Exclusive Provider Organization (EPO) is a plan that allows members to pick from a more extensive network of in-network doctors and see specialists without a referral from their primary care physician. Regarding EPO versus HMO prices, EPO plans are usually more expensive than HMO policies but less expensive than PPO plans. EPO plans often have a more extensive network than HMO plans and do not give out-of-network benefits like PPO plans.
One of the major benefits of EPO vs. HMO is that you won’t have to choose a PCP, and you won’t need a referral to see a specialist. However, it is your responsibility to research if your specialist is part of your network.
Specific optional procedures and tests may require preauthorization or prior authorization to assist you, and your insurance company keeps costs down. If you don’t get preauthorization, your EPO may charge you a hefty fee or refuse to pay benefits at all. This cost-cutting is because the plan only pays for those deemed medically essential.
The services that require preauthorization are included in your plan’s Summary of Benefits and Coverage and Summary Plan Description and include CT scans, MRIs, pricey drugs, some procedures, in-patient stays, and medical equipment.
If you don’t mind being restricted to particular physicians and hospitals but want the freedom to see experts without referrals, an EPO could be right for you.
The difference between HMO and EPO monthly premiums is that EPOs are typically in the center of the pricing range for all plans compared to HMOs, PPOs, and POS plans.
What are some of the benefits of EPOs?
- With an EPO, there is no need for a referral to see a specialist, saving you money on co-pays and time spent seeing your primary care physician.
- It is not required to have a primary care physician.
- Even if you venture outside of your network, emergency care is covered.
- Premiums and out-of-pocket expenditures are often lower with EPOs.
- Your in-network providers will submit your claims on your behalf.
- Some have large, nationwide networks, so you may be able to see a doctor who is part of the network when you travel.
What are the disadvantages of EPOs?
- It’s possible that you won’t keep your present doctor or specialists.
- Unless it’s an emergency, you must use in-network providers, limiting reasonably priced healthcare if traveling.
- Even if your insurer covers out-of-network emergencies, the provider has the right to bill you for the difference between its rates and the payments made by your insurer.
- It is your responsibility to stay connected to your network.
- You are in charge of getting prior clearance for costly treatments and examinations.
What is the Difference Between EPO and HMO?
The fundamental distinction between HMO vs. EPO is you must select a primary care physician (PCP) under an HMO to organize your medical treatment and recommend you to specialists. You can consult experts without a referral if you have an EPO. However, you should first confirm that the healthcare provider is part of your EPO network and if your plan requires prior authorization.
Learn More With Eden Health
If you want more health tips, such as the difference between EPO vs. HMO, visit Eden Health’s “The Central.” Here, we provide a bevy of knowledge that covers health, safety, and wellness tips for the hybrid workforce.
Contact Eden Health to learn more about employer-based health insurance.