Individual and Family Plan Network Types
Individual and family plans are designed for an individual’s specific needs. Some plan types restrict provider choices or encourage you to obtain care from the plan’s network of doctors, hospitals, pharmacies, and other medical service providers. Other plans allow for out-of-network coverage, making it less expensive for you to see out-of-network providers.
Plan types vary by location. You may or may not find all of the plan types mentioned below in one or more metal tiers (Bronze, Silver, Gold, and Platinum).
Examples of Plan Network Types
Health Maintenance Organization (HMO)
An HMO usually limits care to doctors who work for or contract with the HMO. In general, this type of plan doesn’t cover out-of-network care unless there’s an emergency. To be eligible for coverage through an HMO, you may have to live or work in its service area. Furthermore, you need a referral from your primary care physician (PCP) before seeing a specialist.
Point of Service (HMO-POS)
A type of plan in which you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. HMO-POS plans may require you to get a referral from your PCP to see a specialist.
HMO-POS plans often have limitations to cost-sharing coverage, prior authorization, and other plan limitations when seeing out-of-network providers using the Point of Service benefit.
Exclusive Provider Organization (EPO)
An EPO is similar to an HMO, except you don’t have to choose a PCP, nor do you need a referral to see a specialist. Services are only covered if you use doctors, specialists, and hospitals in the plan’s network unless there’s an emergency.
Preferred Provider Organization (PPO)
Unlike an HMO, a PPO doesn't confine you to a provider network to receive covered services. When you use services within the plan’s network, your costs are lower than outside the plan’s network. In addition, you don't need a referral to see a specialist.
Non-Participating Providers
Certain providers may not participate in many of the plans. Make sure you verify in-network status with your insurance carrier before receiving services.