Plan Types

What are the different plan types available on SureCo's platform?

1. HMO - Health Maintenance Organization*
2. PPO - Preferred Provider Organization*
3. EPO - Exclusive Provider Organization*

4. POS - Point of Service*

   *Always refer to the plan's Summary Benefit Coverage (SBC) to verify if you need a referral to see a specialist*

1. HMO (Health Maintenance Organization)

• How it works: Requires members to choose a primary care physician (PCP) and get referrals to see specialists. Coverage is limited to doctors and hospitals within the HMO’s network (except for emergencies).

• Pros: Lower premiums, predictable costs, coordinated care.

• Cons: No out-of-network coverage (except emergencies), limited provider flexibility.

• Example: Kaiser Permanente HMO – you must use Kaiser doctors and facilities.

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2. PPO (Preferred Provider Organization)

• How it works: Offers the most flexibility. Members can see in-network and out-of-network providers without referrals. Out-of-network care is covered but at higher cost.

• Pros: Wide provider choice, no referrals needed, out-of-network coverage.

• Cons: Higher premiums and deductibles than HMO/EPO.

• Example: Blue Cross Blue Shield PPO – you can see almost any provider, but you save more in-network.

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3. EPO (Exclusive Provider Organization)

• How it works: Like a PPO in flexibility (no PCP or referrals required), but with no out-of-network coverage (except emergencies).

• Pros: Lower cost than PPO, no referral requirements, access to large network.

• Cons: No coverage outside the network.

• Example: Oscar EPO or Cigna EPO – you choose providers within the EPO network, but no coverage if you go out-of-network.

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4. POS (Point of Service)

• How it works: Hybrid between HMO and PPO. Requires a PCP and referrals for specialists, but allows out-of-network care (at higher cost).

• Pros: Flexibility to go out-of-network, coordinated care from PCP.

• Cons: More restrictive than PPO, higher cost-sharing for out-of-network care.

• Example: Aetna POS – you’ll pick a PCP but still have out-of-network options if needed.

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✅ Quick Comparison Table

Plan Type	PCP Required	Referrals Needed	Out-of-Network Coverage	Typical Premiums
HMO	Yes	Yes	Emergencies only	$ (lowest)
PPO	No	No	Yes	$$$ (highest)
EPO	No	No	Emergencies only	$$
POS	Yes	Yes	Yes (higher cost)	$$