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Ppo Insurance Plans For Individuals
Everyone must have health insurance now that the Affordable Care Act is in effect, but that doesn't mean health care has become any less confusing. When it comes to insurance coverage, we tend to go with what we know or what we've always had, but the reality is that you have options.
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In California, health insurance plan options primarily include Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). There is also a third option, the Exclusive Provider Organization (EPO), which is gaining popularity in California.
While all of these plans can provide the coverage you need, it's important to understand each one individually and then compare them. Not understanding the difference between HMO, PPO, and EPO plans can lead to significant unexpected costs and discouragement from switching doctors due to changes in insurance coverage. These plans provide coverage, but there are significant differences in how they work and how much they cost.
Whether you're uninsured and looking to buy a plan soon or exploring your options as a California resident, we've provided some insight into HMOs, PPOs, EPOs, and Kaiser Permanente.
Of the three types of plans—HMOs, PPOs, and EPOs—you have HMOs and PPOs at opposite ends of the spectrum, with EPO plans somewhere in the middle. You should first identify the difference between an HMO and a PPO plan. Then you can see where EPO fits in, as a hybrid of the other two.
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HMO plans are primarily about a primary care physician (PCP). Your PCP is the doctor you see for your annual physical or when you are sick. You can choose your PCP, but it must be within the HMO health care provider's local network. Here is more information about HMOs:
But what happens when your PCP doesn't think you need further treatment? Or does your condition not warrant a consultation with a specialist? These situations may arise and you should consider them. As long as you choose a PCP you trust, this is unlikely to cause problems.
All of your health care is provided in the local network - if you see an out-of-network provider, you are responsible for paying out-of-pocket costs. If you have a doctor you love, expect a change in insurance coverage, and are considering an HMO plan, make sure your doctor is in the HMO plan's network. If not, you may need to change doctors so you have a PCP that is in the plan's network.
There is one exception to the HMO network rule. You might be thinking - what if I'm on vacation and have an emergency? In this topic:
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Overall, HMO networks are small, but HMO plans have two advantages—both in the financial category. Since you work in an HMO network, you may never have to make a claim. Instead, your insurance company works directly with your health care providers. Also, HMO plans are always lower cost - they usually have lower monthly premiums and lower out-of-pocket costs.
Yes, this means that PPO plans on the other end of the spectrum are almost always more expensive—however, with increased cost comes increased flexibility and freedom. Still in-network, but you have the freedom to go to out-of-network providers if you want:
With a PPO plan, there is also more flexibility when it comes to choosing a PCP and seeing specialists. If you have a PPO plan, you don't have to have a PCP and can go to any provider you choose, but you'll ultimately save money by choosing an online doctor.
You also don't need a referral from your PCP if you need to see a specialist—that's a decision you're free to make without seeing your PCP first. You may also choose to see a specialist outside of your network, as a PPO plan allows you to do so.
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With all this flexibility and freedom comes higher costs and more involvement in your health care, as you are often planning and coordinating appointments, while the PCP handles most of the care in an HMO plan. If you choose to see a doctor outside of your network, you may also need to gather information and file a claim with your insurance company to get some of the cost covered.
There are some important differences between HMO and PPO plans, and there is no one-size-fits-all solution. What is best for you ultimately depends on your preferences.
There is a third option that is becoming increasingly popular in California - the Exclusive Provider Organization (EPO). This third option is a bit of a hybrid of an HMO and a PPO plan. You will have a lot of freedom with a PPO plan. Here is a list of features for an EPO plan:
Since you're limited to using a specific network with an EPO plan, it's often less expensive than a PPO plan, making it a great solution for people who want more control over their health care without paying significantly more in insurance premiums. Again, you should know if your doctor and any specialists you see are in network, because you will be responsible for all costs if you go to a doctor outside the EPO network.
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California is home to Kaiser Permanente, the oldest and largest medical institution in the country. Founded in 1945 and headquartered in Oakland, California, Kaiser Foundation Health Plan, Inc. is an insurance company serving people in California, Colorado, Georgia, Hawaii, Virginia, Maryland, Oregon, Washington and the District of Columbia.
The foundation also supports Kaiser Foundation Hospitals and The Permanente Medical Group, Inc., a medical group of more than 9,000 physicians. Kaiser Permanente has created its own brand network.
As an HMO, Kaiser has a local provider network in California that includes PCPs, labs, hospitals and pharmacies. If you live in an area without a Kaiser facility, you may be able to get care from places that contract with Kaiser—they don't carry the Kaiser name, but are considered to be in the Kaiser network.
The Kaiser network currently serves eight million Californians through 15,774 physicians, 467 medical offices and 36 hospitals located throughout Northern and Southern California. You can find a Kaiser location through an online search.
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You may have heard of Kaiser Permanente's "Thrive" campaign. This wellness campaign focuses on preventative care and includes 24/7 access to phone nurses, disease management programs, healthy lifestyle programs, and discounts on classes and fitness programs.
In some ways, Kaiser Permanente takes HMO plans to a new level, with physician groups and hospitals at its core instead of being literally affiliated with different health systems. However, it is still an HMO plan at its core and comes with the limitations that define an HMO plan - being in network and managing all of your care by seeing your PCP first.
The first step is to look at your options - all three plans are not available everywhere, so it's best to start by looking at what's available to you. You can start by entering simple information about yourself and your family, if applicable, on our website.
Asking for a free quote will give you a list of options including plan type (HMO, PPO or EPO). Once you know what plans are available, you can begin to consider your priorities.
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There is no winning plan, but there is a plan that will work best for you and your family. Consider how important each of these factors is:
When considering your options, remember that each of these types of insurance plans in California will cover the health care services you need. The way they go about providing this service looks different. Individuals and families come in all shapes and sizes - and so do insurance plans.
Now that you have a little background information on HMO, PPO, and EPO plans, as well as an understanding of how Kaiser Permanente fits, you're ready to get an insurance quote. Whether you are currently uninsured and need insurance or want to shop, we have an online tool that allows you to get free health insurance quotes instantly. Not only that, everyone gets a chance to see
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