For an employee or a patient, multiple health insurance plans can be availed. A patient with such a managed health care plan has assured access to a network of dental care providers. If a patient visits a practice from any in-network doctors or practices, the patient can benefit from lowered rates against visiting an out-of-network practice.
For a visit to a practice that is in-network, the billing system aids in making the documentation and claims process simpler and faster.
Dental care providers too can profit from managed health care plans. There is a greater probability of getting more patients who are in the network. This provides a ready base of customers and consistent work.
As against a fee-for-service plan, a managed healthcare plan offers less flexibility. These plans ensure that a patient is required to visit an in-network healthcare professional. The patient otherwise might have a risk of paying higher fees. One might need a referral of a specialist too to avail of the benefits of such plans.
HMO (Health maintenance organization), PPO (preferred provider organization), POS (point of service), and EPO (exclusive provider organization) plans are different kinds of managed healthcare plans. Due to certain similarities and overlapping nature and offerings, selecting a plan may be confusing for a patient.
There are, however, variations in these plans and there are some options for coverage of dental services and procedures. The insurance organization or network associated with a plan can make a difference to a patient as it determines the practices that can be selected, or the depth of services covered. Understanding how these managed healthcare plans differ, and work can help to shortlist the most suitable healthcare plan and get treatment covered without any surprises.
Before signing up for an insurance plan, one needs to identify how each one compares to the others.
Health Maintenance Organization
A health maintenance organization offers a means to provide a way to take care of the healthcare needs of employees by offering lowered costs. This is done by negotiating with a set of doctors, clinics, and hospitals. A patient needs to avail of the services of these specified providers to get the benefits of reduced fees within the insurance plan.
Generally, an HMO plan has very little flexibility but offers the simplest and easiest means for claims submissions as the network takes care of putting in the claims for the patient.
Preferred Provider Organization
A preferred provider organization provides lowered costs when a patient seeks the services of dentists or practices that are within the network. A patient can visit a practice that is not in the network but there will be a higher charge for the patient.
Point of Service
In a point-of-service plan, a patient can pay a reduced amount if a patient selects a practice or dental care provider that is part of the network. A patient needs to get a referral from the primary care physician before seeing a specialist to avail of a POS plan.
Exclusive Provider Organization
In this managed healthcare plan, a patient can select from the providers within the network and can evade working with any primary care physician. One needs to note that a service utilized outside the network is not liable for coverage.
| PLAN
TYPE |
NETWORK COVERAGE &
RESTRICTIONS |
REFERRALS | OUT-OF-POCKET COSTS |
| HMO | Must stay within the network (emergencies excluded) | Typically
required |
Low |
| PPO | Flexible, staying within the network costs less | May not be required | High |
| EPO | Must stay in-network, except for emergencies | May not be required | Higher than HMO, lower than PPO |
| POS | Flexible, availing services within the network cost less | Needed | Lower than a PPO but costlier than an EPO or HMO plan |
Of all the plans, an HMO plan is generally the least expensive from a family plan employee contribution. From a single coverage employee contribution, it has one of the lowest options available. While POS plans offer great flexibility, they are more expensive than HMOs and EPOs.
A patient can avail of any of these health insurance plans, but one must also consider the amount one will pay as a deductible. A health plan with a high deductible has a lower premium payout.
Understanding the differences between HMO, PPO, POS, and EPO insurance plans can help businesses or patients decide on the ideal health plan. Consulting with insurance experts can offer insights on selecting the optimal health insurance plans.
