Most of us are consumers of a health insurance plan. Whether we purchase it ourselves, through our employer, or hit the lottery and our employer pays for it all—most of us have a health insurance plan.

Almost all of us face some plan changes in 2016, and we have decisions to make in regards to our upcoming plan selection.

The biggest trend for the consumer to battle with over this next enrollment period and into the future will be understanding our ability to see a doctor.

Spoiler Alert!!—Go establish a relationship with your Doctor of Choice now, before they get a full patient load and cut off access to New Patients.

Let’s start with a quick review of the common types of Plans and how each affects your access to the Provider Network:

The hallmark of the PPO Health plan is the freedom to access a specialist without needing a referral from a Primary Care Physician.

In the Midwest and the South region of the United States, the PPO is still the plan of choice for most companies and individuals. With a PPO, you get coverage to a network of providers who are contracted with the health plan, and you also get coverage for providers who are not contracted.

PPO plans incentivize you to use network providers through enhanced cost-sharing for their services.

When receiving coverage outside of the PPO Network, you will incur extra expenses due to reduced coverage and liability for Non-Network Providers “balance-billing” you for rates beyond what the insurance plan deems as reasonable.

The HMO was the birthplace of designating your Primary Care Physician and needing to obtain a referral to see a specialist. HMOs, by nature, have a smaller network of “In-Network” physicians and hospitals.

Your cost for the HMO health plan is typically less, as well as your cost for care, because of the smaller network and more control by the insurance.

Today, some HMOs have abandoned the referral process, and some have maintained it. When purchasing an HMO, you should check to see if a referral is required for some or all care from specialists.

You should also check to see if the Primary Care Physician you would like is currently accepting new patients. In many cities (especially in Texas), you will have many choices of HMO Physicians, but, of those, less than 30% are taking new patients.

Tip: Most HMO providers are also “In-Network” with a PPO or EPO health plan. It is easier to become a new patient while on one of these plans because the doctor gets paid better on these plans. Go establish your relationship now by using your free preventative care on your current plan, before you join an HMO. The process will be easier and better for you. Plus, doctors don’t want your first visit to be a sick-visit, and they won’t schedule you, as such.

The EPO is the fastest growing option and one that really isn’t that different.

With an EPO, you get all the In-Network perks like you do in a PPO. Direct access to specialists and co-pays for services are normal.

The EPO, however, does not cover providers that aren’t contracted. The only coverage that you’ll receive outside of the EPO network will be for Urgent or Emergency care.

A Primary Care Physician may be required on an EPO in some cases; it is good to check before purchasing.

In many regions, the EPO and HMO are the only 2 options left for most consumers.

This stands for Point-of-Service – not the other common acronym.

A POS plan can mean a variety of things as the consumer.   Most plans in North Texas behave identically to a PPO. In other Texas regions, they behave like an HMO.

The key take-away when looking at a POS plan is that you will have some level of coverage for Non-Network providers, and your choice of In-Network providers will likely be smaller than a PPO plan, but not bad.

No one has one of these plan unless you are an out-of-area employee working in a region separate from your employer, or you reside in rural a Montana/Wyoming region. But if you do, you don’t have any restriction or reduction in coverage. On the flip-side, you probably don’t live anywhere that has a robust choice of providers anyway.

With the focus on selecting the right health plan for 2016, we sincerely hope you either have a good doctor relationship, or take advantage of the time between now the next time you are ill to get a doctor/patient relationship established.   This will be key to getting good care and will be paramount in your plan selection for 2016 and beyond.

Share This