Choice Stories

September 16, 2021

Comparing Health Plans – PPOs, HMOs, and EPOs

Open enrollment is underway across California for health insurance coverage effective in Q4 and early 2022. You may be evaluating coverage options and costs. A multi-product, multi-carrier health insurance exchange is affordable and allows you to offer more choices.

In California, businesses with up to 100 employees can choose from the Covered California public exchange or the CaliforniaChoice private exchange. Both offer a variety of plans in all four Affordable Care Act (ACA) metal tiers: Bronze, Silver, Gold, and Platinum. You can choose from Health Maintenance Organization (HMO) plans, Preferred Provider Organization (PPO) plans, or Exclusive Provider Organization (EPO) plans, including High Deductible Health Plans and Health Savings Account-qualified coverage.

Understanding Plan Differences

How do you know which plan type might be right for you and your employees? That depends on your needs – or the needs of your family – and whether you have specific doctors, specialists, or hospitals that you want to be able to visit.

HMOs

A Health Maintenance Organization (HMO) plan offers members:

  • Access to care through a network of providers (seeking care outside the network is not permitted, except in case of a medical emergency)
  • Care coordination through a Primary Care Physician (PCP)
  • Required referrals to visit a specialist (an added co-pay often applies)
  • Reduced premiums and lower co-pays (vs. a PPO)

PPOs

Some individuals prefer Preferred Provider Organization (PPO) coverage because it offers:

  • Freedom to visit any medical provider in the PPO network
  • Discounted rates for care through contracted medical providers and hospitals
  • No referrals required to visit specialists
  • Flexibility to use a non-network provider (although higher out-of-pocket costs, such as a separate deductible and out-of-pocket maximum, may apply)

EPOs

Often described as a sort of hybrid between an HMO and a PPO, an Exclusive Provider Organization (EPO) offers:

  • Reduced costs: lower premiums than PPOs and typically no co-pays when visiting an in-network specialist
  • Self-referral to in-network specialists (care outside of the network may not be covered, except in case of an emergency)

HSA-Qualified Plans

Health Savings Account (HSA) qualified coverage is available in multiple ACA tiers through HMO, PPO, or EPO plans. With an HSA plan, an individual can pay for qualified medical expenses with tax-advantaged dollars. Link here to read a Society for Human Resource Management (SHRM) article on 2021 limits for HSAs and HDHPs.

Network Availability by Plan Type

As you review your coverage options, consider your personal or family health care needs.

If it’s important to be able to keep a preferred doctor after moving to a new health plan, you’ll want to compare the networks for the plans being considered. Does at least one network include your preferred doctor(s)? Your employee benefits broker can help you search for doctors and prescriptions that are “in network” and covered by the health plan(s) you’re considering. Don’t be hesitant to ask to your broker about “who’s in” and who is not.

Each ACA metal tier and plan type offers different network access. For example, within the CaliforniaChoice private exchange program, an Anthem Blue Cross EPO plan offers access to the Small Group Prudent Buyer network in the Bronze tier; Select HMO, Select PPO, and CaliforniaCare HMO networks are added in the Silver, Gold, and Platinum tiers for HMO and PPO plans.

For Health Net, in the Bronze tier, only the CommunityCare network is available; however, WholeCare, Salud HMO, and Full network options are available in other tiers. Kaiser Permanente and Western Health Advantage both offer full network access for all of their plans through CaliforniaChoice.

For Cigna + Oscar, the LocalPlus network is available for all plans and tiers. Sharp Health Plan offers two network choices: Premier and Performance; access varies by HMO plan. The same Sutter Health Plus network is offered on all plans. UnitedHealthcare offers four networks (SignatureValue, Advantage, Alliance, and Harmony) for plans offered through CaliforniaChoice in the Silver, Gold, and Platinum tiers.

Talk With a Broker to Learn More

To get more information about what plans are available in your local area – and what providers are in each plan network – talk with a broker. He or she can deliver a customized quote for your business and your employees. If you don’t already have a broker, we can help you find one here.

Your Beginner's Guide to Choosing a Small Business Employee Benefits Program

Do you need help choosing the right health benefits for your employees?
This guide can help!