Navigating through the Healthcare Industry ( insurance plans)
One fine day, we will all look back at these terms – PPO, HMO, EPO, Deductibles and laugh about how we had to jump through hoops to figure out which coverage to get. For now though, the waters are tricky to navigate – and one has to understand the key differences between PPOs and HMOs (and their hybrid child – the EPO)
The Biggest Surprise – Pre-Authorization
Requires Pre-authorization? – This to me, is the DECIDER question – this essentially allows insurance companies to overrule your need for services. Since I do not trust any insurance company, I like to avoid this pre-authorization – and hence prefer plans without this need. In effect, that limits me to HMOs.
| Pays for out-of-network care? | No | Yes | No |
|---|---|---|---|
| Requires pre-authorization? | Yes | Yes | No |
| Requires a primary care physician who acts as a gatekeeper to access other services? | No | No | Yes |
| Requires referrals to see a specialist? | No | No | Yes |
| How are doctors paid by the health plan? | Paid only when they provide a service. More services = more $. | Paid only when they provide a service. More services = more $. | Paid the same amount each month whether they provide lots of services or none. |
Note that PRE-AUTHORIZATION is different from REFERRALS – in case of referrals, PPOs are more flexible than HMOs. In case of pre-auths however, HMOs win hands down.
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