Navigating through the Healthcare Industry ( insurance plans)

One fine day, we will all look back at these terms – PPO, HMO, EPO, Deductibles and laugh about how we had to jump through hoops to figure out which coverage to get. For now though, the waters are tricky to navigate – and one has to understand the key differences between PPOs and HMOs (and their hybrid child – the EPO)


The Biggest Surprise – Pre-Authorization

Requires Pre-authorization? – This to me, is the DECIDER question – this essentially allows insurance companies to overrule your need for services.  Since I do not trust any insurance company, I like to avoid this pre-authorization – and hence prefer plans without this need. In effect, that limits me to HMOs.



What’s the Difference Between EPOs, PPOs, and HMOs?
Pays for out-of-network care? No Yes No
Requires pre-authorization? Yes Yes No
Requires a primary care physician who acts as a gatekeeper to access other services? No No Yes
Requires referrals to see a specialist? No No Yes
How are doctors paid by the health plan? Paid only when they provide a service. More services = more $. Paid only when they provide a service. More services = more $. Paid the same amount each month whether they provide lots of services or none.


Note that PRE-AUTHORIZATION is different from REFERRALS – in case of referrals, PPOs are more flexible than HMOs. In case of pre-auths however, HMOs win hands down.

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1 Comment

  • Did Obama drop his socialized hetlahcare program because of the economy?I saw his new ad campaign in Nevadabarrackobama.comBarack Obama and Joe Biden’s PlanOn health care reform, the American people are too often offered two extremes government-run health care with higher taxes or letting the insurance companies operate without rules. Barack Obama and Joe Biden believe both of these extremes are wrong, and that’s why they’ve proposed a plan that strengthens employer coverage, makes insurance companies accountable and ensures patient choice of doctor and care without government interference.The Obama-Biden plan provides affordable, accessible health care for all Americans, builds on the existing health care system, and uses existing providers, doctors and plans to implement the plan. Under the Obama-Biden plan, patients will be able to make health care decisions with their doctors, instead of being blocked by insurance company bureaucrats.Under the plan, if you like your current health insurance, nothing changes, except your costs will go down by as much as $2,500 per year.This is the SAME as MC CAIN’S Plan.

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