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Your insurance: What is the difference between HMOs, PPOs and EPOs?

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Your insurance: What is the difference between HMOs, PPOs and EPOs?

Health insurance is a hot topic these days, but it’s also incredibly confusing. What’s covered? What’s not? And what do all of those abbreviations mean?

We regularly deal with insurance companies and claims, because contrary to what many people believe, policies often cover reconstructive and medically necessary plastic-surgery procedures. That means we know a fair amount about the ins and outs of health insurance, and we thought a quick primer on the different types would be helpful.

Health Maintenance Organizations (HMO)
Typically, an HMO plan requires all of your healthcare services to go through one primary care physician. If you need non-emergency care from a specialist, for example, you first would have to get a referral from your primary care doctor — although women may not be required to get a referral for OB/GYN visits, well-woman exams, etc. Visits to providers who aren’t in the HMO’s network usually are not covered by your policy.

  • Advantages: No need to fill out claims forms, lower out-of-pocket costs
  • Disadvantages: Less choice than other plans, having to get referrals can be inconvenient

Preferred Provider Organizations (PPO)
A PPO plan allows you to see any healthcare provider you choose, with no need to get a referral or select a primary care physician. If you use providers within your plan’s network, your copays will be smaller and more services are likely to be covered than if you go outside the network. You’ll have higher out-of-pocket costs for non-network providers, and your servicemight not be covered at all.

  • Advantages: More freedom than HMOs, lower costs if you stay within network
  • Disadvantages: Higher out-of-network costs, which can limit flexibility

Exclusive Provider Organizations (EPO)
These plans blend elements of HMOs and PPOs — you must utilize services from a limited network of providers to be covered; however, you don’t have to choose a primary care physician and referrals aren’t required. Premiums can be lower than a similar HMO plan, but the networks typically are smaller, and out-of-network providers usually won’t be covered at all.

  • Advantages: Lower costs, no need to choose primary care physician or get referrals
  • Disadvantages: Limited networks, high out-of-network costs

Will my procedure be covered?
If your procedure is reconstructive or medically advisable, rather than for the sake of appearances — such as breast reconstruction for a cancer patient, or a breast reduction to alleviate back pain — all or part of the surgery could be covered, depending on your policy and your network. Newport Beach plastic surgeon Dr. Tenley Lawton will explain your options and help you determine what’s right for you. Contact her today for your consultation.

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