When it comes to choosing a health plan (PDF) that fits your needs, the process may seem daunting. Open Enrollment is around the corner (Sept. 16 through Oct. 11), which is a time to switch plans, enroll, add or remove dependents, or cancel coverage.
CalPERS offers health-eligible members three types of health plans to choose from—a health maintenance organization (HMO), a preferred provider organization (PPO), and an exclusive provider organization (EPO).
The type of plan you choose will determine how much you pay out of pocket and what doctors you can visit.
What is an HMO?
An HMO plan includes a network of providers such as doctors, medical groups, hospitals, and labs that you must go through to receive care. Key points to remember:
- You’ll have a primary care doctor who manages your care. If you need to visit specialists or get tests, your primary care doctor will make the referral or request authorization.
- There is usually a copay for most services.
- An HMO has a geographically restricted service area, so availability of HMO plans is based on your home or work ZIP code.
Pros and Cons of an HMO?
If you’re watching your wallet and don’t anticipate many doctor visits, an HMO plan may be the right choice for you. HMOs have lower monthly premiums and lower out-of-pocket costs. For example, there are no deductibles in CalPERS HMO plans. And you won’t need to file claim forms when receiving care in the HMO network. Unless it’s an emergency, however, HMO plans require you stay within their network for care. Also, if your current doctor isn’t part of the HMO’s network, you’ll need to choose a new doctor within the network.
What HMOs Does CalPERS Offer?
Basic (non-Medicare) plans include Anthem Blue Cross Select and Traditional, Blue Shield Access+ and Trio, Kaiser Permanente, Sharp Performance Plus, UnitedHealthcare’s SignatureValue Alliance and Harmony, Western Health Advantage and Health Net Salud y Mas.
What is a PPO?
A PPO plan provides more flexibility in choosing your health care providers, but it may cost more than an HMO. Key areas to remember:
- Your maximum copay or coinsurance is less when you stay in network for services.
- You can see a specialist and access many types of services without a referral. While you’ll be matched with a primary care provider, you can choose not to go through them for care.
- You pay for services until you meet your deductible.
- After meeting your deductible, you pay coinsurance, which is a percentage of the costs.
- In-network services are generally cheaper than out-of-network services.
Pros and Cons of a PPO?
You’ll have more flexibility to use in-network and out-of-network providers and can visit specialists without a referral. But PPOs typically have higher out-of-pocket costs than HMO plans.
What PPOs Does CalPERS Offer?
PERS Platinum and PERS Gold. PERS Platinum is available nationwide.
What is an EPO?
An exclusive provider organization (EPO) falls somewhere between an HMO and PPO. It provides the same covered services and lower costs of an HMO along with a broad network and some of the flexibilities of a PPO. Key areas to remember:
- You pay copays, but you don’t pay deductibles or coinsurance, like you would in a PPO plan, so your overall out-of-pocket costs may be lower. You’re required to obtain care from the plan’s network of preferred providers.
- If you receive care out-of-network, you’re required to cover the full cost of services, except for emergency medical care.
- You’ll be matched with a primary care provider, but don’t need a referral to see a specialist as long as they are within the preferred provider network.
Pros and Cons of an EPO?
You don’t need a referral to see specialists. However, the specialist must be in the EPO network of preferred providers for your insurance to cover the visit. EPOs also offer access to a broad network of providers. An EPO is generally only available in certain rural areas, so check availability.
What EPOs Does CalPERS Offer?
Blue Shield Access+ EPO.
Get Started
Check out the Choosing the Right Health Plan for You video and use our Health Plan Search by ZIP Code tool or log in to your myCalPERS account to use the Search Health Plan tool to find plans offered in your area, the plans your doctors participate in, and compare monthly premiums.
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FAQs
Basically HMOs and EPOs (in the purest sense) require you to stay in network whereas PPOs have out-of-network benefits but usually you will pay more out-of-network. A health plan that requires you to have a primary care physician and requires you to be referred by that doctor to any specialists is an HMO.
What is the difference between EPO and HMO PPO? ›
An exclusive provider organization (EPO) falls somewhere between an HMO and PPO. It provides the same covered services and lower costs of an HMO along with a broad network and some of the flexibilities of a PPO.
Why would a person choose a PPO over an HMO? ›
PPOs Usually Win on Choice and Flexibility
If flexibility and choice are important to you, a PPO plan could be the better choice. Unlike most HMO health plans, you won't likely need to select a primary care physician, and you won't usually need a referral from that physician to see a specialist.
What are 3 major differences between HMO and PPO insurance? ›
Choosing between an HMO or a PPO health plan doesn't have to be complicated. The main differences between the two are the size of the healthcare provider network, the flexibility of coverage or payment assistance for doctors in network vs out of network, and the monthly payment.
Why is EPO better than a PPO? ›
EPO and PPO plans are both solid options that can help cover medical costs for you and your family. If you're looking for coverage that reaches beyond a limited network, then a PPO may be right for you. However, EPOs tend to be more affordable and offer sufficient coverage for in-network medical services.
What is the downside of an EPO? ›
EPO Cons. Out-of-network care is not covered: Out-of-network care is not covered under EPO plans, except for emergency care. If you want to see a doctor that is not in-network, you have to pay the full medical bill.
Why do doctors prefer PPO? ›
HMO plans might involve more bureaucracy and can limit doctors' ability to practice medicine as they see fit due to stricter guidelines on treatment protocols. So just as with patients, providers who prefer a greater degree of flexibility tend to prefer PPO plans.
What are three disadvantages of HMO? ›
Disadvantages
- If you need specialized care, you will need a referral from your primary care physician to an in-network provider.
- Must see in-network providers for care-less flexibility than a PPO plan.
Disadvantages
- Higher monthly premium.
- Higher out of pocket expenses.
- Must monitor in-network vs out-of network to control cost.
PPO insurance plans allow plan participants to choose from a larger network of doctors and hospitals without needing a referral to see a specialist. While PPO plans allow for out-of-network care, they tend to have higher monthly premium costs and annual deductibles than other types of health insurance plans.
A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan's network (except in an emergency).
Is Covered California HMO or PPO? ›
If you're going PPO, that usually means you'll be looking at Anthem Blue Cross Covered California and Covered California Blue Shield. In the PPO world, you'll find more options and you'll likely end up paying more money in monthly premiums to have this choice.
Do more people have HMO or PPO? ›
2022 Employer Health Benefits Survey
PPOs are the most common plan type. Forty-nine percent of covered workers are enrolled in PPOs, followed by HDHP/SOs (29%), HMOs (12%), POS plans (9%), and conventional plans (1%) [Figure 5.1].
Why is EPO better than HMO? ›
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.
What is the biggest difference between HMO EPO PPO and POS healthcare plans? ›
In a nutshell, these summaries generally say that HMOs and POS plans require a referral from a primary care doctor in order to see a specialist, while PPOs and EPOs do not, and that PPOs and POS plans cover out-of-network care, while HMOs and EPOs do not.
Who benefits from EPO? ›
EPO is used mostly to relieve the itchiness caused by skin conditions, such as eczema and dermatitis. It is also used to ease breast tenderness from premenstrual syndrome (PMS) or other causes, and to help manage menopausal symptoms.
What does EPO mean in insurance? ›
A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan's network (except in an emergency).
What is better, HMO pos or PPO? ›
PPO health insurance allows you more freedom to get care anywhere, while a POS plan may allow out-of-network care but demand a primary care referral. A PPO health insurance plan doesn't typically require that you name a primary care provider to oversee your care.
What does PPO mean in healthcare? ›
Preferred provider organization (PPO) A type of medical plan in which coverage is provided to participants through a network of selected health care providers, such as hospitals and physicians. Enrollees may seek care outside the network but pay a greater percentage of the cost of coverage than within the network.
What does HMO mean in insurance? ›
An HMO is a health maintenance organization. The Department of Managed Health Care (DMHC) oversees all HMOs in California and some other kinds of health plans. An HMO is a kind of health insurance that has a list of providers, such as doctors, medical groups, hospitals, and labs.
