Difference Between HMO And EPO

We heard about many organizations. Let’s discuss two important health insurance organizations in this article i.e. Hmo and Epo. The full form of HMO is a health maintenance organization. And the full form of EPO is an Exclusive provider organization. As the name sounds both the terms are different from each other. 

HMO vs EPO

The main difference between HMO and EPO is that HMO must get a referral to see a specialist. HMO stands for Health maintenance organization. whereas An EPO does not require any referral. EPO stands for Exclusive provider organization. Both two organizations are good for your health plans.

HMO vs EPO

HMO is a health plan which offers a local network plan to doctors and hospitals. Premium plans are required to take this plan. Usually, HMOs have lower premiums. In an HMO plan, you must need a provider or PCP within your network. There is a relationship between providers and doctors who work for the HMO.

EPO plan does not need to have a provider, PCP, or any referral to see a specialist. EPO is an in-network plan. An in-network plan means streamlining the process when making appointments. There are no out-of-network benefits. Doctors and facilities that work in EPO take charge of every service.

Comparison Table Between HMO and EPO

Parameters of ComparisonHMOEPO
CareAn HMO or Health maintenance organization provides more restricted and managed careAn EPO or  Exclusive provider organization provides broader, less managed care.
Primary Care PhysicianHealth maintenance organizations require PCP.Sometimes PCP is required in an Exclusive provider organization or EPO.
Requirement of referralHealth maintenance organizations require a referral to see a specialist.No referral is required to see a specialist in an Exclusive provider organization.
Pre-authorization requiredNo, PCP referral is enough in the case of a Health maintenance organization.Yes, usually required in the case of an Exclusive provider organization or EPO.
Network sizeThe network size is medium in Health maintenance organizations.The network size is Medium and large both in Exclusive provider organizations.

What is HMO?

A budget-friendly way to secure your life is a health maintenance plan. What else do we need if we have a budget-friendly health plan? HMO is the cheapest type of health insurance because it has fixed copays, low premiums, and deductibles. In HMO you have to select doctors within their connections. When you initially sign in for HMO you have to select PCP or a primary care physician or a doctor you will see for your regular checkups. For PCP you need someone to refer you before going to a specialist.

Specialist means for what you need a doctor like a skin doctor or a dermatologist. it depends on you for choosing the specialists whom you trust the most. If your budget is low and not as such a medical issue, that HMO plan is good for you. This plan covers out-of-network physicians if you pay somewhat more premiums than an HMO, but you will have to pay more to in-network doctors. PCP is the heart of the operation.

Health maintenance organizations have a stronghold in the individual market. Pros of HMO are- Lower premiums and lower costs than PPO. Cons of HMO- Need to say in the network, Need referral.

What is EPO?

The full form of EPO in health care is an exclusive provider organization. EPO is a type of health insurance that covers services from hospitals, doctors, and other care providers in your network. Your health insurance does not reimburse any fees incurred by seeing someone who is not in the network; only the emergency care is usually covered.

Primary care physicians are generally known as PCP.  And PCP plans come under health insurance and EPO insurance plans require selecting PCP. When you take PCP then your PCP doctor provides you with preventive care as well as provides you the treatment of minor and chronic illnesses. To see a specialist, EPO health insurance plans do not require a reference from your primary care physician. And it is the best and only feature of the EPO health insurance plan. When compared to other types of health insurance, an EPO plan has a higher out-of-pocket cost since the insurance begins to cover all of your medical expenditures.

Because the providers in your insurance company have arrangements with the network. EPOs may also provide cheaper monthly charges. EPO plans, for example, pay all fees incurred by doctors or health professionals who are part of the network.

Main Differences Between HMO and EPO

  1. HMO- A pocket-friendly plan whereas EPO- A larger or out-pocket network that makes life easier for everyone.
  2. In HMO it may be more difficult to take authorization for tests and procedures whereas In EPO It might be excellent for people who desire reduced rates and don’t want to see a primary care physician.
  3. HMO has a narrow network whereas EPO has a PPO network.
  4. HMO is not a combination of any other health insurance whereas EPO is a combination of an HMO and PPO health insurance organization.
  5. HMO does not provide out of network care whereas EPO needs pre-authorization for it.

 Conclusion

This article will assist you in selecting the best sort of plan for your medical and provider needs. Many consumers are unsure what the various health insurance plan options imply for them. Here you can understand both the two health insurance plans The HMO and EPO with their differences. There are many types of health insurance plans but here we study only two.

And these two plans are mostly taken by people. When you seriously have a problem and need a specialist then you must take the insurance plans. Otherwise, it is good that you have no such serious medical issues. When you enroll in a premium plan, EPO covers all of your expenses at once, but you will be responsible for a portion of the costs through co-pays. Pre-authorization may be required if you wish to see a physician who is not in your network.

References

  1. https://journals.sagepub.com/doi/abs/10.1177/0046958018779654
  2. https://www.sciencedirect.com/science/article/pii/S0002934303005400
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