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HMOs, PPOs, EPOs & POS

From the Show: Health Radio
Summary: What's the difference between HMOs, PPOs, EPOs and POS?
Air Date: 6/3/16
Duration: 10
Host: Melanie Cole, MS
Guest Bio: Marianne Eterno, President of Government Relations for GTL
Marianne Eterno Marianne Eterno began her insurance career in 1987 at the former Golden Rule Insurance Company in Indianapolis, Indiana, and moved to Chicago in 1992, when she accepted a position with Celtic Insurance Company.

Marianne came to Guarantee Trust Life Insurance Company (GTL) in 1996, as a compliance and government relations consultant, and formally joined the company in 1997. As Assistant Vice President of Government Relations, she represents GTL in both the state and federal arenas, drives coalition development for the company, and serves as the company's media and public relations spokesperson.

In addition to sitting on committees for every major insurance trade association, Marianne serves on the Board of Directors of RetireSafe, a 400,000 member grassroots advocacy organization for senior citizens and as the Executive Director for the Council for Affordable Health Insurance.
HMOs, PPOs, EPOs & POS
There are so many insurance choices that it can be tough to pick a health care plan.

Everything is based on networks. A network is a list of doctors, hospitals and providers.

An HMO (health maintenance organization) is most restrictive. HMOs are comprised of a small list where you have to select a primary care doctor from that list. Insurers must show you the list before you pick a health care plan. You have to see your primary care doctor for each symptom to get a referral to see a specialist. Women can also select a gynecologist without a referral. If you go outside of the network or go to a specialist without a referral, you may have to pay 100% out of pocket.

The only exception for needing a referral is in the case of an emergency. Emergency room visits do not require referrals. HMO reimbursements for doctors are typically lower than PPO reimbursements. HMOs keep costs down for the insurance company. This is a good choice for a fairly healthy person.

A PPO (preferred provider organization) is a larger organization than an HMO. There is no gatekeeper to your healthcare. You don't need to pick a primary care doctor and you can go to anyone on the list at any time, specialists included. If you go outside the network, you'll pay more of the cost but not 100%. The premium costs more and the deductible may be higher. If you're going to use a lot of care and want more flexibility, a PPO might be your best option.

An EPO (exclusive provider organization) is not as restrictive. You don't need to pick a primary care doctor and you can see any specialist on the list. You have the same number of network options as an HMO. There is no coverage if you go off the list.

POS (point of service) is a combination of HMO and PPO. You select a primary care doctor. You need a referral to see a specialist and you have a larger network. You get some coverage out of network.

The first thing you should do when picking a plan is to start with the network. Look at the list to see the availability of doctors in your area. If there are lots of options and you see your doc on the list, that may be the right plan for you.

Health insurance expert and President of Government Relations for GTL, Marianne Eterno, joins host Melanie Cole to discuss the differences between HMOs, PPOs, EPOS and POS.
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