California Health Insurance Plan Options: HMO, PPO or EPO

Everyone has to have health insurance now that the Affordable Care Act is in place, but that doesn’t mean healthcare has gotten any less confusing. We tend to go with what we know, or what we’ve always had when it comes to insurance coverage, but the reality is that you have options.

In California, health insurance plan options primarily include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). There is also a third option, Exclusive Provider Organization (EPO), which is growing in popularity in California.

While all of these plans can provide the coverage that you need, it’s important to understand each of them individually and then compare them to one another. Failing to grasp the differences between HMO, PPO and EPO plans could lead to significant unexpected costs and disappointment in having to switch doctors due to a change in insurance coverage. These plans provide coverage, but there are substantial differences in how they work and how much they cost.

Whether you’re without insurance coverage and looking to purchase a plan shortly or are just exploring the options you have as a Californian, we’ve provided some insight to HMOs, PPOs, EPOs and Kaiser Permanente.

The Difference Between EPO, HMO and PPO Plans

Of the three plan types — HMO, PPO and EPO — you have HMO and PPO at two opposite ends of the spectrum, with EPO plans somewhere in the middle. You should recognize the difference between HMO and PPO plans first. Then you can see where the EPO fits in, as a hybrid of the other two.

In general, the difference between HMO and PPO plans fall into a few categories — cost, network and control. The term “network” refers to a group of doctors, specialists, hospitals, labs, etc. Costs of HMO plans are usually cheaper but come with a more restricted network and less control overseeing specialists.

PPO plans, on the other hand, typically come with a higher price tag but also more flexibility when it comes to the network and control overseeing healthcare professionals. We’ve included specifics on each of these plan categories below.

Health Maintenance Organization (HMO)

HMO plans primarily revolve around a primary care physician (PCP). Your PCP is the doctor you go to see for annual physicals or when you’re sick. You can choose your PCP, but they must fall within the HMO’s local network of healthcare providers. Anytime you have a problem, you schedule an appointment with that PCP, and if they believe you need additional treatment, you will be referred to a specialist, who also falls within the local network of healthcare providers.

For you, as the patient, this plan is very hands off. Everything is determined and coordinated through your PCP. But what happens when your PCP doesn’t think you need additional treatment? Or that your condition doesn’t warrant going to see a specialist? These situations can occur and you should consider them. In HMO plans, your PCP is treated as a gatekeeper to your healthcare. As long as you choose a PCP you trust, this isn’t likely to present any issues.

All of your healthcare is provided within a local network — if you see a provider outside of the network, you are responsible for paying the cost out of your pocket. If you have a doctor you like, anticipate a change in insurance coverage and are considering an HMO plan, make sure your doctor is in the HMO plan’s network. If not, you’ll have to switch doctors, so you have a PCP who falls within your plan’s network.

There is one exception to the HMO network rule. You may be wondering — what if I’m on vacation and have an emergency? In this case:

  • Your HMO plan would usually cover the cost as if the emergency occurred in your network.
  • However, it must be accepted by the insurance company as a true emergency.

Advantages of an HMO

Overall, HMO networks are small, but there are two benefits of an HMO plan — both within the financial category. Since you’re working within the HMO network, you’ll probably never have to file a claim. Instead, your insurance company works directly with your healthcare providers. Also, HMO plans almost always cost less — they usually have lower monthly premiums and less out of pocket expense.

Preferred Provider Organization (PPO)

Yes, this means PPO plans, falling on the opposite end of the spectrum, are almost always more expensive — however, with the additional cost comes added flexibility and freedom. There is still a network, but you have the freedom to go to providers outside of your network if you want:

  • Out-of-network providers usually come with a higher out of pocket expense, but it’s possible to make that choice.
  • Having the option to go out of network is often helpful for people who may have a doctor they like and don’t want to change when they get a new insurance provider.

With a PPO plan, there’s also more flexibility when it comes to selecting a PCP and seeing specialists. If you have a PPO plan, you are not required to have a PCP and can go to see any provider you choose, but you will ultimately save money by choosing a doctor in the network.

Advantages of a PPO

You also don’t need to have a referral from your PCP if you need to see a specialist — that’s a decision you have the freedom to make without going to see your PCP first. You might even choose to see a specialist who’s out of your network, because on a PPO plan you can do so.

With all of this flexibility and freedom comes a higher price tag and a higher level of involvement in your healthcare, as you’re often the one scheduling and coordinating appointments, whereas a PCP takes care of the majority of that in an HMO plan. If you choose to see a doctor outside of your network, you may also need to gather information and submit the claim to your insurance company to get part of the cost covered.

There are a few critical differences between HMO and PPO plans, and there is no one-size-fits-all solution. The one that is best for you ultimately depends on your preferences.

Exclusive Provider Organization (EPO)

There is a third option that is becoming increasingly popular in California — Exclusive Provider Organization (EPO). This third option is a bit of a hybrid of the HMO and PPO plans. You’ll have many of the same freedoms you have with a PPO plan — for example, you won’t need to commit to a PCP or have a PCP referral every time you want to go to a specialist.

However, instead of having complete freedom to choose between a preferred network, as you do with a PPO plan, and out-of-network, you’ll have an exclusive network you must use, much like the network that comes with an HMO plan. Also, like the HMO plan, you’ll be covered out of network in the case of an emergency.

Advantages of an EPO

Since you do have a restriction of using an exclusive network with the EPO plan, it is often cheaper than a PPO plan, making it an excellent compromise for those looking to have more control over their healthcare without paying significantly more in insurance premiums. Again, you must know whether or not your doctor and any specialists you see are in the network, as you will be responsible for all of the costs if you go to a doctor who is out of the EPO network.

What Is CA Kaiser Permanente?

California is home to the country’s oldest and largest HMO, Kaiser Permanente. Founded in 1945 and headquartered in Oakland, California, the Kaiser Foundation Health Plan, Inc., insurance provider serves people in California, Colorado, Georgia, Hawaii, Virginia, Maryland, Oregon, Washington and the District of Columbia.

The organization also backs Kaiser Foundation Hospitals and The Permanente Medical Group, Inc., a physician group practice of over 9,000 physicians. Kaiser Permanente has created its own branded, network.

As an HMO, Kaiser has a local network of providers in California that includes PCPs, laboratories, hospitals and pharmacies. If you live in a region where a Kaiser facility does not exist, you’re able to get care from places Kaiser has contracted with — they don’t carry the Kaiser name, but they are considered to be in the Kaiser network.

The Kaiser network currently serves over eight million Californians through 15,774 physicians, 467 medical offices and 36 hospitals located throughout northern and southern California. You can view Kaiser locations through an online search.

Locations Covered in California by Kaiser Plans

The HMO breaks down the areas it serves in the different regions of the state. Northern California:

  • Central Valley
  • Roseville
  • Santa Cruz
  • Sacramento
  • San Jose
  • Santa Clara
  • East Bay
  • Fresno
  • Greater San Francisco
  • Greater Southern Alameda
  • Marin/Sonoma
  • Napa/Solano
  • Diablo
  • Redwood City
  • South Sacramento

 

Southern California:

  • Coachella Valley
  • Orange County
  • Kern County
  • San Diego County
  • Tri-Central Area
  • Inland Empire
  • Metro Los Angeles/West Los Angeles
  • West Ventura/Valleys

You may have heard of Kaiser Permanente’s campaign called “Thrive.” This wellness campaign emphasizes preventative care and includes 24/7 access to nurses over the phone, disease management programs, healthy lifestyle programs, and class and fitness program discounts, among others.

In some ways, Kaiser Permanente takes HMO plans to a new level, literally having its medical groups and hospitals at its core, rather than affiliating with various health systems. However, it is still an HMO plan at its base and therefore comes with the restrictions that define an HMO plan — having to stay within the network and managing all of your care through first going to see a PCP.

Which of These California Health Insurance Plan Options Is Best for Me?

The first step is taking a look at what your options are — not all three plans are offered everywhere, so it’s best to start by taking a look at what’s available to you. You can begin by entering some simple information about yourself and your family, if applicable, on our website.

Requesting a free quote will give you a list of options, including the plan type (HMO, PPO or EPO). Once you know what plans are available, you can begin to consider your priorities.

There is no winning plan, but rather a plan that will be a better fit for you and your family. Consider how important each of these factors is:

  • Cost — If you’re on a strict budget and finding the cheapest healthcare option is your priority, then an HMO plan will likely be the best fit for you. You could also explore EPO plans if you’re looking for a balance between affordability and control.
  • Network — If you want the ability to have some of your costs covered whether you see a doctor who’s in the network or out of the network, and you have room in your budget for a higher premium cost, a PPO plan will probably be a better fit for you.
  • Control — Think about how you feel about your PCP managing your care. If that’s something you have a strong opinion about, then it will be a deciding factor. If you like the idea of your PCP managing your care, an HMO plan will be a good fit for you. If, on the other hand, you’d like to avoid referrals from your PCP when you need or want to see a specialist, a PPO or EPO plan is probably going to be a better fit.

When you’re considering your options, remember each of these types of insurance plans in California will get you the healthcare services you need. The way they go about delivering those services just looks different. Individuals and families come in all shapes and sizes — and so do insurance plans.

EPO, PPO and HMO Health Insurance Quotes in CA

Now that you have some background information on HMO, PPO and EPO plans, as well as an explanation of how Kaiser Permanente fits in, you’re ready to get an insurance quote. Whether you’re currently uninsured and in need of coverage or want to shop around, we have an online tool that gives you the opportunity to get free health insurance quotes instantly. Not only will you get a chance to see all of your options, but also you can find out if you qualify for government assistance.

All you need to do to get started is enter your gender, date of birth and zip code. The free quotes you get will give you all the details you need, including the plan category (HMO, PPO, EPO), the carrier name, the full price of the plan, the price you pay, a link to view benefits and more. Get started by requesting a free quote today.

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