Choosing the best health plan for patient care is one of the most difficult decisions for some patients and their families because of the fine line distinguishing which plan suits them best. However, every plan is designed to suit a patient according to the kind of treatment they need, the cost of the treatment and the insurance covering every kind of treatment plan. Therefore, there are three main kinds of treatment plans that are offered in general, namely, HMO, PPO, and POS (Web MD, 2016). There are fine differences between the three, based on the need of primary physician care, referral to a specialist or other services, whether health care services have been authorized before, whether the health care plan covers the cost of the care outside the plan, how much cost-shared health care is covered outside of insurance and whether any insurance needs to be filed, and paperwork needs to be done (Web MD, 2016).
The first kind of healthcare plan is named HMO or Health Maintenance Organization. An HMO plan is one where a patient chooses their Primary Care Physician through a chosen set of local healthcare providers (Medicare, n.d.). The Primary Care Physician will then recommend the in-network of the specialists or any hospitals if required by the patient. Every step of the care is organized and taken care of by the Primary Care Physician (Healthcare, 2016). An example of this is when a patient begins to suffer from back pain, they will visit their Primary Care Physician as the first step. If the Primary Care Physician is unable to help the patient, they would give the patient a reference of a trusted and qualified in-network specialist who might be able to help. However, HMO plans are unable to cover any out-of-network care providers. The exception in the case is when the patient is in emergent condition and needs healthcare immediately. There are several benefits of the HMO plan such as any extra medical costs and monthly premiums which are lower in affordance than the other plans. Also, for a person who has not seen many personal care physicians (PCP) and does not know of many, then the cost of looking for one through this plan is lower. A patient, when chooses a PCP, is encouraged to build a good relationship with them because they will then take the time to refer them to a good specialist and healthcare providers (Network, 1996).
However, there is a case when a patient has a good relationship with other doctors out of their network and knows how to get more doctors from a flexible plan of being able to choose their healthcare; then they can go for another plan, which is the Preferred Provider Organization (PPO).
The PPO or the Preferred Provider Organization is a kind of health plan where medical providers like doctors and hospitals or clinics are hired on contracts in order to build a network of participating providers of healthcare. Any other doctors, hospitals, and healthcare providers are hired at an additional cost of hiring (Humana, 2016).
A PPO plan has the basic perk of allowing a patient to choose their desired doctors and specialists without the need for references from a personal care physician (PCP). However, this service also comes with giving a higher monthly premium and more out of the budget medical costs which are paid by a patient apart from their insurance coverage of the medical expenses (Plans, n.d).
There is, therefore, an additional freedom associated with the use of PPO plans for healthcare. An example can be a patient who is suffering from pain in her wrist, and she relates it to osteoporosis. If she has a PPO plan for her healthcare, then she can go see any rheumatologist for a consult and check up, without the need for a referral from any specific physician in her network. This freedom can lead patients to various doctors of their choice, and it also takes up the additional cost for it (Insurance, 2016).
The third kind is the POS plan. An acronym for Point of Service, this is a plan combining the other two kinds of plans i.e. HMO and PPO. In this kind of plan, a patient is required to choose and assign their healthcare to a physician who will act as their primary health care provider (Fontinelle, 2014).
The patient has the choice of choosing from out of their network as well. However, this choice comes with a cost which is to pay for an out-of-network procedure from their own pocket. This is also implied only if the primary care physician is not asked for a referral (Fontinelle, 2014). If the referral is taken from the PCP, then the cost is not included in the healthcare for choosing a specific doctor. In such a case, the cost of healthcare is mostly covered by the plan and payment is upon insurance (Davis, 2016).
Out of the three forms of healthcare plans, POS is the least chosen as mostly people choose HMO or PPO. The reason for this is that the person making the insurance is going to make copayments for the plan. The in-network payments are cheaper, about $10 to $25 per every appointment. Moreover, the POS plans have no deductibles for the in-network consultancy by the client, therefore; it has a greater edge over the PPO plans (“Point-of-service plan (POS),” 2016). However, the out-of-network services are not paid for by the plan which means that when a patient makes an out-of-network consultancy, they are required to pay the full cost of the plan until they can reach the plan’s designated deductible (“Point-of-service plan (POS),” 2016). Hence, if a person is not using any out-of-network services, then they can be better off which HMO plans due to lower premiums. Nevertheless, for those who travel a lot, a POS plan would be better as these plans have a nationwide coverage and will benefit a person in any place in the country (“Point-of-service plan (POS),” 2016).
References
Davis, E. (2016, August 24). HMO, PPO, EPO, POS—What’s the difference & which is best?
Retrieved August 24, 2016, from Very well, https://www.verywell.com/hmo-ppo-epo-pos-whats-the-difference-1738615
Fontinelle, A. (2014). Point-of-service plan - POS. In . Retrieved from
http://www.investopedia.com/terms/p/pointofservice-plan-pos.asp
Healthcare. (2016, March ). Type of plan and provider network. Retrieved August 24, 2016, from
https://www.healthcare.gov/choose-a-plan/plan-types/
Humana. (2016). What is an HMO? Understand HMO plans and HMO insurance. Retrieved
August 24, 2016, from https://www.humana.com/individual-and-family/products-and-services/medical-plans/what-is-hmo
Insurance. (2016, August 8). Understanding the difference between HMO, PPO, and POS.
Retrieved August 24, 2016, from http://www.insurance.com/health-insurance/health-insurance-basics/understanding-the-difference-between-hmo-ppo-and-pos.aspx
Medicare. Health maintenance organization (HMO). Retrieved August 24, 2016, from
https://www.medicare.gov/sign-up-change-plans/medicare-health-plans/medicare-advantage-plans/hmo-plans.html
Network, B. C. (1996). How are HMO, PPO and EPO plans different? Retrieved August 24,
2016, from http://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works/difference-hmo-ppo-epo.html
Plans, M. Medicare home. Retrieved August 24, 2016, from
http://www.bcbsm.com/medicare/help/faqs/works/hmo-ppo-pos.html
Point-of-service plan (POS). (2016). Retrieved August 24, 2016, from
http://healthcoverageguide.org/reference-guide/coverage-types/point-of-service-plan-pos/
WebMD. (2016, August 18). HMO, PPO, EPO: What health plan is best? Retrieved August 24,
2016, from WebMD, http://www.webmd.com/health-insurance/20140815/hmo-ppo-epo-hows-a-consumer-to-know-what-health-plan-is-best
