Health Care Enrollment 2020 POS, EPO, ​and HDHP Plans

As you prepare for open enrollment, which starts November 1st thru December 15th for individual and family plans. It’s essential to understand the differences between plans. Differences between an HMO and PPOwas recently covered in a post. The purpose of this article is to provide an overview of the POS, EPO, and HDHP plans.

Point of Service (POS)

A POS plan has been referred to as a hybrid of HMO and PPO plans due to having the qualities of both. Like a PPO, you can access care from an in-network or out-of-network provider and facilities. If you to choose to go out-of-network, you will likely pay more out of pocket for this privilege.

Like an HMO, you may be required to choose a Primary Care Physcian (PCP) as your in-network physician to coordinate and help manage your health care needs.  

Example: (assuming deductible met)

• In-network provider, your specialist copay is $30 with 20% coinsurance
  • A specialist visit is $500  
  • You pay: $150.00  
  • 20% of $500 is $100 plus $50 copay 
• The out-of-network provider maybe 40% coinsurance
  • A specialist visit is $500
  • You pay $200
  • 40% of $500 is $200

A POS offers tiered options: 1. For in-network, 2. Out of network to help balance the cost-sharing should you seek out-of-network care.

Advantages of a POS

•    Lower cost if you stay in-network

•    Flexibility and cost-sharing if you want to go out-of-network

•    Access to PCP to coordinate and manage health care needs

Exclusive Provider Organization (EPO)

An EPO plan is often called exclusive as you are only covered for in-network services for the groups the EPO is contracted with. There are exceptions:

•    Emergency care is covered

•    The EPO may not have the specialist you need in their network. In this case they may refer you out-of-network. Be sure to communicate with your EPO and get pre-authorizations for all care.

•    If you join an EPO from another plan and are being treated for a condition, you may want to continue care with the specialist treating you. This provider may not be in the EPO network. The EPO may be willing to work with you. Alternatively, they may refer you to a specialist within the EPO network.

Advantages of an EPO

•    Lower cost 

•    Referrals and PCP not required

•    You like the cost savings and don’t mind seeing the providers within the EPO network

High-Deductible Health Plan (HDHP)

An HDHP plan, also referred to as a Consumer Driven Health Plan (CDRP), can have features similar to an HMO or PPO depending on the plan you choose. Once you have met your deductible, then your coinsurance will kick in. Once all your costs have been met per your maximum out-of-pocket, your medical costs will be covered. HDHP plans also have a Health Savings Account  (HAS) benefit allowing you to save money pre-tax for any unexpected medical expenses.

For 2020 the minimum deductibles are $1400 for individual and $2800 for family. Out-of-Pocket maximums which include deductibles and copays but not premiums for an individual is $6900 and $13,800 for the family  For more information including HSA contribution limits: refer to IRS Announces 2020 limits and maximums

Key points to remember:

•    The average deductible can range from $3000-$5000, which means until this is met, you are paying full cost for office visits and pharmacy.

•    HDHP plans do cover preventative care before the deductible.

•    You can participate in a Health Saving Account (HSA) to offset the costs before deductible or out-of-pocket maximums are met.

Advantages of an HDHP

•    Lower monthly premium

•    Includes preventative care before the deductible

•    You pay less out-of-pocket costs in premiums if you are not in need of medical care to treat a chronic condition or pay for maintenance medication.

Summary of POS, EPO and HDHP Plan requirements:

Plan Type	POS	EPO	HDHP
Referral	Required	Not required	Varies
Cost	Lower in network, higher out-of-network	Lower premiums, lower in network, out of network self-pay	Lower Premiums
Network	In-network and out-of-network. (PCP referral required), Emergencies are covered	In-network only, Emergencies covered	Varies Emergencies covered
Care Coordination	Health care data is not shared via one Electronic Healthcare System (EHR)	Health care data is not shared via one Electronic Healthcare System (EHR)	Varies
Primary Care Physician	No	No	Varies

Overall plan summary average annual and monthly premiums:

Plan Type	Average Annual Premiums **	Average Monthly Premiums **
POS	$7185 (individual) $19,838 (family)	$573 (individual) $1,613 (family)
HDHP	$6,412 (individual) $18,890 (family)	$540 (individual) $1,603 (family)
HMO	$7,238 (individual) $20,697 (family)	$598 (individual) $1,606 (family)
PPO	$7,675 (individual) $21,683 (family	$648 (individual) $1,797 (family)

**Kaiser Family Foundation, 2019 Employer Health Benefits Survey.  EPO not included in study