Since I was unable to summarize in my previous article, I will continue to summarize the insurance system in the U.S. in this article.
If you have not read our previous article on HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization) insurance systems, please click below.
Private Insurance in the U.S.
EPO (Exclusive Provider Organization)
EPO is a relatively new medical insurance system in the U.S. It is similar to HMO in that it allows only in-network medical facilities and providers, but differs from PPO in that co-payments are lower than those of PPO even when using out-of-network medical facilities and providers. However, it differs from PPOs in that co-payments are lower than those of PPOs, even when using out-of-network providers.
How EPO Works
An EPO has a network of medical facilities and providers that subscribers can use. Only medical institutions and providers within this network can be used, but if you use medical institutions and providers within the network, your co-payments will be lower.
EPO does not require you to select a primary care physician (PCP).
↑Same as PPO
Advantages of EPO
Relatively lower premiums: Premiums are less expensive than those of PPOs.
Lower out-of-pocket costs: Even if you use out-of-network providers, your out-of-pocket costs are lower than those of a PPO.
Easier to manage medical expenses: Because you can only use in-network medical facilities/providers, it is easier to manage your medical expenses.
Disadvantages of EPO
Limited choice of health care providers: Only in-network health care providers are available, so your choices are limited.
May require referrals: You may need a referral from your PCP to see a specialist.
May have limited emergency coverage: Out-of-pocket costs may be higher for emergency visits to out-of-network providers.
People for whom EPO is suitable
People who want to reduce their medical costs: EPO is suitable for people who want to reduce their medical costs because it is less expensive than PPO and has lower co-payments when using out-of-network medical facilities and providers.
People who value preventive care: Like HMOs, which encourage regular checkups and immunizations, EPOs focus on preventive care.
People who want to use a specific health care provider: EPO is an option for people whose usual health care provider is in the EPO’s network.
POS (Point-of-Service Plan)
A relatively new health insurance plan in the U.S. that combines elements of HMOs and PPOs, with copayments similar to HMOs when using in-network providers and copayments similar to PPOs when using out-of-network providers. The system has the following characteristics
How the POS works
POS has a network of medical facilities and providers available to subscribers. When using medical institutions/providers within this network, the subscriber must be referred by his/her primary care physician (PCP), similar to an HMO, and the co-pay is lower, similar to an HMO. On the other hand, if you use an out-of-network medical facility or provider, you can be seen without a referral as with a PPO, and your copay is higher as with a PPO.
Advantages of POS
High flexibility: combines elements of HMOs and PPOs, thus combining the low out-of-pocket costs of HMOs with the flexibility of PPOs.
Some choice of providers and providers: In-network providers and providers as well as out-of-network providers and providers can be used.
Relatively flexible emergency care: If you have an emergency and visit an out-of-network provider, your co-pay will be lower than an HMO.
Disadvantages of POS
Higher premiums: premiums are higher than HMOs and PPOs.
Complicated copayments: Copayments are more complicated because copayments are similar to HMOs when using in-network providers and similar to PPOs when using out-of-network providers.
Difficulty managing medical expenses: co-payments are more complex, making it more difficult to manage medical expenses.
Who is a good candidate for POS?
People who want a balance of flexibility and copayments: POS combines the low copayments of an HMO with the flexibility of a PPO, making it a good choice for people who want a balance of flexibility and copayments.
People who sometimes want to use a specific provider: If your regular provider is in the POS network, POS is an option for you.
People who value emergency services: Suitable for people who may need to visit an out-of-network healthcare provider in an emergency.
Summary
In this and the previous article, I have summarized the insurance system in the U.S., and I have learned that there is no such system as the National Health Insurance in Japan.
The National Health Insurance in Japan is not available to all people in the U.S., but only to those who meet certain conditions.
Next time, I will summarize the public health insurance system called Medicare.
