Differences between PPO, EPO and HMO

[Salty]

Hello, and Happy Holidays
We are considering a move out of state in the future ( 1-2 years). One sincere concern is health insurance for the younger of the two of us. I am 55 and purchase my health insurance through the ACA or Obamacare website.
As I " shop" other states for healthcare, I see some states have HMO's ( what I have in MA) some have PPO's ( which I assume is what I was familiar with in corporate America, any doctor, hospital etc ) but some have EPO's. What are these? Are they " better " than HMO's? worse? Are there any other types of plans I should be aware of? Living in MA, our plan, even though technically an HMO , mostdoctors and hospitals participate in it.
Any insight would be appreciated!!

 

[harley]

I had a big problem with this too, and am not absolutely sure I understand it even now. We had been with Kaiser Permanente HMO for about 35 years. Once we moved out of an area they covered we had to change. We went with a PPO plan (BCBS), which is, as you say, the standard any doc any hospital, cheaper in the network. From what I could figure out, EPO was basically network only, with no coverage outside of the network. I couldn't figure out why anyone would go with something so restrictive, but maybe it is much cheaper as far as in network costs. I'm looking forward to hearing what others have to say, because I was really confused too.

I'd go back to KP in an instant if it was available to me. But even when we were in their area, once we started snow birding and were outside of their area for half the year it was a massive hassle to deal with medical issues. We'd have to be full time in their coverage area before we'd switch back.

 

[Bamaman]

You might want to go into Wikipedia and see the differences in the three plans. Explanations can get rather lengthly.

We once had Kaiser Permanente HMO. It was fine for family services like kids with the sniffles. But at the time my wife had pretty serious issues that the HMO specialists would not address--almost like they didn't have the budgets for such issues. When we went back to a conventional policy, a new physician solved the problem in one outpatient clinic visit. As us baby boomers age, I would hate to think we had to deal with a HMO and their conservative approach to medicine.

 

[easysurfer]

Never heard of EPO. Now I'm curious as to what the E stands for.

 

[up_north]

Never heard of EPO. Now I'm curious as to what the E stands for.

"Expensive" (if you go out of network)

No, actually an EPO is an Exclusive Provider Organization, which is consistent with the explanations given in this thread.

 

[MissMolly]

Never heard of EPO. Now I'm curious as to what the E stands for.

"Exclusive"

 

[easysurfer]

"Exclusive"

Thank you. Saved me some googling .

 

[MichaelB]

Just to add some confusion, insurers are not consistent with the use of PPO and EPO across the country. Many of BCBS exchange plans are labeled EPO when in fact they are PPO plans with a pediatric dental option that is EPO.

A PPO plan allows the member to access the network without prior authorization, the member is allowed to choose any network provider, and there usually is separate additional coverage for using non-network providers for non-emergency care.

In any case, it is a good idea to not just accept the insurer's categorization of the plan but to check the actual network and coverage requirements.

 

[Sunset]

We used to have a PPO, and now we have a HMO which I think stands for Horrible Medical Option !!

For example, I just asked the Doc about the new shingles vaccine, he said it might be covered next year, so he is recommending all patients wait until 2019 !

 

[VanWinkle]

We used to have a PPO, and now we have a HMO which I think stands for Horrible Medical Option !!

For example, I just asked the Doc about the new shingles vaccine, he said it might be covered next year, so he is recommending all patients wait until 2019 !

That may be due to a new vaccine that is being rolled out in the next year or so. I recently got my vaccine, but was offered to wait for the new one. I took the old vaccine instead of waiting.

 

[Splash]

EPO (Exclusive Provider Organization) plans usually do not pay anything if you go out of network unless it is an emergency and even then the benefits paid typically are limited to what the insurance company would have paid if you had gotten service in network. This reduces insurance company's costs by not having to pay out of network providers without pricing agreements in place.

Someone asked "why would anyone pick such a restrictive plan?". Because the only ACA plans available in my area for 2018 are EPO.

 

[LARS]

"Expensive" (if you go out of network)



No, actually an EPO is an Exclusive Provider Organization, which is consistent with the explanations given in this thread.

Not to quibble, but the "E" doesn’t stand for expensive, but nonExistent as you have zero, nada, nothing outside of network: not even benefit of negotiated rates.

 

[Sunset]

That may be due to a new vaccine that is being rolled out in the next year or so. I recently got my vaccine, but was offered to wait for the new one. I took the old vaccine instead of waiting.

It is a new shingles vaccine, about 95% effective and lasts longer, vs the old shingles vaccine that is only 78% effective and declines effectiveness quite a bit over the next few years.

I understand a few months of waiting until it is available, but a year? When the FDA and CDC both approve it.

The difference is great:
"Studies presented to the committee show that Zostavax is 51% effective against shingles and 67% effective against postherpetic neuralgia.
In contrast, Shingrix is 97% effective against shingles for people between the ages of 50 and 69 and 91% effective for people 70 or older. It is 91% effective against postherpetic neuralgia for people 50 and older. These rates are based on evidence presented to the committee from clinical trials with over 38,000 total participants.
"

CDC recommends new shingles vaccine to replace older one - CNN

 

[irishgal]

There are also 2 kinds of HMOs. The staff model is what Kaiser is, the doctors and ancillary staff actually work for Kaiser, are paid by Kaiser as a staff member, not as a “contracted provider”. If you are a Kaiser member you must go only to a Kaiser facility with rare exceptions. The other type of HMO is a restrictive network, such as Healthcare Partners, where independent providers can join the network as providers- are are subject to the “medical necessity” guidelines set forth by the HMO.

In my opinion Kaiser is a pretty good organization. They have been flexible enough to survive the crazy healthcare landscape for what, 50 years, and have started contracting with the big insurance groups to allow the large insurers to give access to their hospitals. The Kaiser spine and joint facility in Irvine Californian is a Center of Excellence, meaning their outcomes have won them that “title” if you will.
As a side note although I was in healthcare I never worked for Kaiser.

 

[Scuba]

My understanding is that an EPO is sort of a hybrid of an HMO and PPO, at least in CA. If you’re in an HMO, the network and resulting approved treatments are limited to that provider (ie if you have Kaiser you cannot go outside if Kaiser). A PPO has maximum flexibility; reimbursement is better in network but you can go out of network if you wish and still get significant coverage. When I researched EPO’s recently, they seemed to provide a bit more flexibility and choice than an HMO, but be much more restrictive than a PPO.

My conclusion was that as long as we can afford it, we’ll stick with a PPO.

 

[Scuba]

You might want to go into Wikipedia and see the differences in the three plans. Explanations can get rather lengthly.

We once had Kaiser Permanente HMO. It was fine for family services like kids with the sniffles. But at the time my wife had pretty serious issues that the HMO specialists would not address--almost like they didn't have the budgets for such issues. When we went back to a conventional policy, a new physician solved the problem in one outpatient clinic visit. As us baby boomers age, I would hate to think we had to deal with a HMO and their conservative approach to medicine.

I avoid HMO’s ... there is a reason they’re referred to as “managed care.” My doc said he interviewed with a major HMO years ago. They had very strict rules as to protocols, time spent with each patient, etc., and he said the drugs on their approved formulary excluded the newest, most advanced treatments. Maybe not a big deal if you’re being treated for a minor ailment, but if DH or I get cancer or another major health issue, we want the freedom to go to completely independent providers for second opinions as well as the flexibility to opt for the latest and best treatments.

Our doc has known each of us for 20+ years and spends as much time with us as we need when we go in to see him.

 

[DEC-1982]

We once had Kaiser Permanente HMO. It was fine for family services like kids with the sniffles. But at the time my wife had pretty serious issues that the HMO specialists would not address--almost like they didn't have the budgets for such issues. When we went back to a conventional policy, a new physician solved the problem in one outpatient clinic visit. As us baby boomers age, I would hate to think we had to deal with a HMO and their conservative approach to medicine.

Although I have been with Kaiser of Georgia for 15-20 years, and am fairly happy with it for my needs so far, I generally agree with your comments. Something significantly out of the ordinary is not handled well by them.

At the same time, they are not pushing the latest product promoted by somebody, which might be 1% better and 1000% costlier, just because they can make more money.

 

[Rianne]

The plans the ACA offered for our income were POS (Point of Service), HMO and PPO. There was 0 coinsurance offered with anything "out of network" for the HMO. So if we traveled anywhere outside our insurance scope, we'd pay the full amount charged by the hospital, except for an ER visit. With the POS, the coinsurance is 50%, so they pay 50% for any out of network doctor or service. The premium was almost the same for HMO and POS. Do not know why anyone would take the HMO, very limiting very managed.

 

[aja8888]

Do not know why anyone would take the HMO, very limiting very managed.

How about I give you a couple of reasons:

1. That's all that is available.

2. That's all one can afford.

I'm sure there are more reasons, but that's all I am familiar with.

 

[MichaelB]

How about I give you a couple of reasons:

1. That's all that is available.

2. That's all one can afford.

I'm sure there are more reasons, but that's all I am familiar with.

Those are two excellent reasons, and I'm sure represent the vast majority (>90%) of HMO choices.

 

[MRG]

I avoid HMO’s ... there is a reason they’re referred to as “managed care.” My doc said he interviewed with a major HMO years ago. They had very strict rules as to protocols, time spent with each patient, etc., and he said the drugs on their approved formulary excluded the newest, most advanced treatments.

I'm not sure that's just HMOs limiting the formulary. My PPO last year wanted my DM to come back from the beyond to swear I needed flowmax.

Last plan, similar from the same insurance company, no problem. Two years later, no deal. Prior approval? No, take these other medications first, step therapy. One was a made my BP 60/40, the other too dizzy to stand up!

 

[Scuba]

Those are two excellent reasons, and I'm sure represent the vast majority (>90%) of HMO choices.

A lot of people in CA seem pretty happy with Kaiser. Many employers here offer only Kaiser, no PPO option, so people get used to it. Most of the plans in our market are either Kaiser or BCBS. Anthem pulled out of ACA plans in this market this year. We were able to keep our pre-ACA “grandfathered” Anthem PPO plan, at least so far. DH and I have always had access to a PPO so we hope to keep this coverage indefinitely.