Every EPO has a list of health care providers called a provider network. This network offers every imaginable type of health care service including doctors, specialists, pharmacies, hospitals, labs, x-ray facilities, speech therapists, home oxygen, and more.

In an EPO health plan, you can only get health care services from in-network providers. If you get care out-of-network, the EPO won’t pay for it; you’ll be stuck paying the entire bill yourself. Accidentally getting out-of-network care can be a very expensive mistake when you have an EPO.

It’s ultimately your responsibility to know which providers are in-network with your EPO. For example, you can’t assume that, just because a lab is down the hall from your EPO doctor’s office, that lab is in-network with your EPO. You have to check. Likewise, don’t assume that the imaging facility that did your mammogram last year is still in-network with your EPO this year. Provider networks change. If you make that assumption and you’re wrong, you’ll have to pay the entire mammogram bill yourself.

There are three exceptions to the in-network requirement:

• The EPO doesn’t have an in-network provider for the specialty service you need. If it happens to you, pre-arrange the out-of-network specialty care with the EPO—keep your EPO in the loop.
• You’re in the middle of a complex course of specialty treatment when you become an EPO member and your specialist isn’t part of the EPO. Your EPO will decide whether or not you may finish the course of treatment with your current physician on a case-by-case basis.
• True emergencies. If you’re having a stroke, heart attack, or other true emergency, you should go to the nearest emergency room whether or not it’s in-network with your EPO. Most EPOs will cover the cost of emergency care received at the nearest out-of-network facility as though it was in-network care. However, if you need to be admitted to the hospital from the ER, your EPO may ask the out-of-network ER to transfer you to an in-network hospital for admission.

Your EPO health plan won’t require you to have a primary care physician, although getting a PCP is still a good idea.

Neither will your EPO require you to get a referral before seeing a specialist. This makes it easier to see a specialist since you’re making the decision yourself, but you need to be very careful that you’re seeing only specialists that are in-network with your EPO.

You don’t have to hassle with bills and claim forms when you have EPO health insurance since all of your care is provided in-network. Your in-network health care provider bills your EPO health plan directly for the care you receive. You’ll just be responsible for paying your deductible, copayment, and coinsurance.

To offset HDHPs’ higher deductibles, most individuals enrolled in HDHPs are eligible to set up a tax-advantaged health savings account (HSA).  An HSA enables you to pay for eligible health expenses, including expenses before the deductible has been met, with tax-free dollars. Increasingly referred to as a consumer-driven health plan (CDHP), an HDHP coupled with an HSA can help you take control of your healthcare expenses and save for the future.

With family coverage in an HDHP, health plan benefits don’t begin for any member of the family until the entire family deductible has been paid. As each family member incurs medical expenses, the amount they pay toward these expenses is credited toward the family’s deductible. When these expenses add up to the family deductible, the HDHP coverage kicks in and starts paying its share of the cost of health care expenses for each and every member of the family.

In an HDHP, the family deductible can be met by in two different ways:

1. One family member has high health care expenses. By paying those health care expenses, he reaches the family deductible and coverage kicks in for the entire family.
2. Several different family members have smaller health care expenses. The family deductible is met when these smaller expenses added together reach the family deductible amount.

The difference between the traditional type of health insurance deductible system and the family deductible in an HDHP health plan is that the individual deductible is eliminated in family HDHP coverage. There is only one way the HDHP health plan will begin to pay benefits for any family member: the family deductible has been met.

In contrast, with a non-HDHP plan, the family deductible can’t be met by the health care expenses of one family member alone. It takes the added deductibles of several family members together to reach the family deductible.

When covered by an HMO plan, you’re required to have a primary care physician, or PCP. You have the right to choose your own primary care physician as long as he or she is in the HMO’s network. If you don’t choose one yourself, the HMO will assign you one.

Your primary care physician, usually a family practitioner, internist or pediatrician, will be your main doctor and coordinate all of your care. Your relationship with your primary care physician is very important in an HMO, so make sure you feel comfortable with him or her. If you don’t, then switch doctors.

Your primary care physician will be the one who decides whether or not you need other types of care. For example, your primary care physician decides when you need to see a specialist, need physical therapy, or need medical equipment like a wheelchair or oxygen at home.

In order to see the specialist, get the wheelchair, or have the physical therapy, your primary care physician has to make a referral. Without a referral, you don’t have permission for those services and the HMO won’t pay for them.

Requiring a referral from your primary care physician is part of how your HMO makes sure the treatments, tests and specialty care you’re receiving are medically necessary.

Every HMO has a list of health care providers that are in its provider network. Those providers cover every imaginable type of health care service including doctors, specialists, pharmacies, hospitals, labs, x-ray facilities, speech therapists and more.

You can only get health care services from in-network providers. If you get care out-of-network, the HMO won’t pay for it; you’ll be stuck paying the entire bill yourself.

Accidentally getting out-of-network care can be a very expensive mistake when you have an HMO. Fill a prescription at an out-of-network pharmacy and the HMO won’t pay for it. Accidentally get your blood tests done by the wrong lab and you could be stuck with a bill for hundreds or even thousands of dollars depending on the blood tests and the lab.

It’s ultimately your responsibility to know which providers are in-network with your HMO. This isn’t very complicated with an HMO like Kaiser Permanente where the network providers are all in the same building and see no one but Kaiser patients. But, if you have an HMO with an insurer like United Healthcare, Aetna, or WellPoint, its in-network providers won’t always be at the same location and often see patients that aren’t HMO members. You can’t assume that, just because a lab is down the hall from your doctor’s office, that lab is in-network with your HMO. You have to check.

There are three exceptions to the requirement to stay in-network:

• True emergencies.
• The HMO doesn’t have an in-network provider for the specialty service you need. This is rare. But, if it happens to you, pre-arrange the out-of-network specialty care with the HMO—keep your HMO in the loop.
• You’re in the middle of a complex course of specialty treatment when you become an HMO member and your specialist isn’t part of the HMO. Most HMOs decide whether or not you may finish the course of treatment with your current physician on a case-by-case basis.

Cost-sharing like deductibles, copayments, and coinsurance are kept to a minimum with an HMO. Many HMOs don’t require any deductible at all and only require a small copayment for other services like doctor visits or prescriptions. Because of their low cost-sharing and low premiums, HMOs are considered one of the most economical health insurance choices.

You don’t have to hassle with bills and claim forms with an HMO since all of your care is provided in-network. In fact, with HMOs, many providers don’t get paid based on providing a particular service to you on a particular day, known as the fee-for-service model. Instead, they get a certain amount of money each month for every HMO member, and they provide whatever covered care those HMO members need. For example, a provider might get $50 per month for each HMO member whether those HMO members use any services that month or not.

This method of paying providers cuts back on office visits, treatments, tests or procedures that aren’t absolutely necessary. There’s no financial incentive for a provider to provide any care that isn’t necessary. It also eliminates the hassle of dealing with claims.

A PPO uses cost-sharing to help keep costs in check. When you see the doctor or use health care services, you pay for part of the cost of those services yourself in the form of deductibles, coinsurance and copayments.

Cost-sharing is part of a PPO’s system for making sure you really need the health care services you’re getting. When you have to pay something for your care, even a small copayment, you’re less likely to use unneeded services frivolously. However, thanks to the Affordable Care Act, PPOs can’t require any cost-sharing for preventive services.

Cost-sharing helps offset the cost of your care. The more you pay toward the cost of your care, the less your PPO pays and the lower it can keep monthly premium charges.

A PPO limits who or where you can get health care services by the use of a network of health care providers with whom it has negotiated discounts. A PPO’s network includes not just physicians, but every imaginable type of health care service like labs, x-ray facilities, physical therapists, medical equipment providers, hospitals, and out-patient surgery centers.

The PPO provides an incentive for you to get your care from its network of providers by charging you higher copays or coinsurance when you get your care out-of-network. For example, you might have a $40 copay to see an in-network physician, but a 50 percent coinsurance charge for seeing an out-of-network physician. If the out-of-network physician charges $250 for that office visit, you’ll pay $125 rather than the $40 copay you would have been charged if you’d used an in-network physician.

Still, although you pay more when you use out-of-network health care providers, one of the perks of a PPO is that, when you use out-of-network providers, the PPO at least contributes something toward the cost of those services. This is one of the ways a PPO differs from an HMO. An HMO won’t pay anything if you get your care out-of-network.

One of the ways a PPO makes sure it’s only paying for health care services that are really necessary is by requiring you to get pre-authorization before you have expensive tests, procedures, or treatments. If you don’t get permission from your PPO before you have these services done, the PPO won’t pay.

PPOs differ on which tests, procedures, services and treatments they require pre-authorization for, but you should suspect you’ll need pre-authorization for anything expensive or anything that can be accomplished more cheaply in a different manner. For example, you might be able to get prescriptions for older, generic drugs filled without a pre-authorization, but have to get your PPO’s permission for an expensive brand-name drug to treat the same condition.

When you or your doctor asks the PPO for pre-authorization, the PPO will probably want to know why you need that test, service, or treatment. It’s basically trying to make sure that you really need that care, and that there isn’t a more frugal way to accomplish the same goal. For example, when your orthopedic surgeon asks for pre-authorization for your knee surgery, your PPO might require you to try physical therapy first. If you try the physical therapy and it doesn’t fix the problem, then the PPO may go ahead and pre-authorize your knee surgery.