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Health plan definitions

Drowning in open enrollment acronyms? We can help!

If you’ve ever had a baffling text exchange with a teenager, you’re well practiced for deciphering the alphabet soup of open enrollment, iykwim.*

It helps to do your hw* and jsyk,* irl* there are details to every plan you will want to look at. But here are some basic definitions of the four types of plans you’ll run across during open enrollment.

HMO, PPO, EPO and POS are all abbreviations that define different forms of managed care. That means they are designed to keep health care costs controlled without sacrificing quality of care. How they do that accounts for the differences between them.

HMO stands for Health Maintenance Organization. These plans are usually among the most reasonably priced, both in terms of premiums and deductibles, as well as how much you’ll be expected to pay out of pocket. But there’s a catch. HMOs are usually the least flexible health plans available.
With an HMO you can only get care from a specified group of providers. On top of that, you must get a referral from your primary care provider for any specialist visit. So if you need to see a dermatologist you must first get a referral from your primary care provider. That’s an added layer of inconvenience for most. If you see someone outside of the HMO? You’ll pay everything out of pocket. The only exception is emergency visits.

PPO is a Preferred Provider Organization. This is the most popular and usually most expensive type of coverage. You don’t need a referral to see a specialist with a PPO. While a PPO will still have certain physicians and hospitals it considers “in-network” (or “preferred”), you’ll still have some coverage with an “out-of-network” provider, just at a lower rate. For example, a visit to a preferred provider might be covered at 90 percent but an out-of-network doc only at 50 percent. (The exact figures will be in your plan description.) 

EPO stands for Exclusive Provider Organization. Like an HMO, an EPO will only cover out-of-network services in a true emergency. Their network isn’t preferred, it’s required. The biggest difference is that an EPO does not require a referral. So if you want to see a dermatologist, you can just make an appointment with one — as long as they are in-plan.

POS** is a Point of Service Plan. Like an HMO, with a POS plan you will need to get a referral from your primary care provider before you can see a specialist. However, as with a PPO, you still have the flexibility to see providers who are out-of-network if you’re willing to pay more of the bill.

HTH* BFN*


* If you know what I mean
* Homework
* Just so you know
* In real life
* Hope this helps
* Bye for now
** If you see your teen typing POS, they probably aren’t talking about health care. In teen-speak it means “Parent over shoulder.”  You can freak them out by saying something like, “That seems kind of suss.” But be warned, this may enter you into a conversation you will not understand.