Plan Designs
PPO (Preferred Provider Organization)
A Preferred Provider Organization (PPO) provides coverage for both in-network and out-of-network services. Members can utilize in-network benefits without requiring referrals, enabling them to select any participating provider for their healthcare needs. Furthermore, this plan does not mandate the choice of a Primary Care Physician, though it often tends to be more expensive.
EPO (Exclusive Provider Organization)
An Exclusive Provider Organization (EPO) provides in-network benefits. A referral is not usually required, and the plan allows members to use any participating provider. The assignment of a primary care physician is usually not required, but strongly recommended.
HMO (Health Maintenance Organization)
A Health Maintenance Organization (HMO) provides coverage exclusively for in-network providers. Typically, a referral from the members designated primary care physician is necessary. Because HMOs do not include out-of-network services, they are often the most budget-friendly option.
POS (Point of Service)
A point of service (POS) plan provides benefits for services both in-network and out-of-network. A referral may be needed. This plan enables members to receive care from participating or non-participating providers, though it could lead to increased out-of-pocket expenses. While choosing a primary care physician is generally not mandatory, it is highly recommended.
QHDHP (Quality High Deductible Health Plan)
A Qualified High Deductible Plan (QHDHP) integrates a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) with traditional coverage, offering a tax-advantaged method to save for future medical costs.
Plan Types
Fully-Insured
Fully-insured health plans require employers to pay a fixed premium to an insurance carrier for their employee's medical expenses, offering financial certainty but possibly leading to higher costs.
ICHRA
Individual coverage plans reimbursed fully or partially by the employer through an HRA (ICHRA). This plan allows employees to purchase their own individual health insurance and customize their coverage to fit their individual needs. This plan can offer great savings to employers and employees while preventing exorbitant premium hikes.
Level-Funded
Level-funded plans are a hybrid of self-funded and fully-insured options. Employers pay into a claims account, purchase stop-loss insurance, and cover administration fees. If there is any reserve capital, this money is distributed back to the employer and the insurance company, typically in a 50/50 split. This plan type is often a lower monthly premium than fully insured plans as the employer retains partial risk with the insurer.
Self-Funded
Self-funded health plans require employers to front money that gets set aside to cover expected employee medical costs (claims account), purchase stop-loss insurance and administrative fees. An insurance company will manage the payments funded through the employer and if there is any reserve capital, this money is distributed back to the employer and the insurance company, typically in a 50/50 split. This plan type offers the potential for cost savings at the end of each year.
MEC
​A Minimum Essential Coverage (MEC) plan provides the minimum coverage required by the Public Health Service Act. This plan provides applicable large employers with 50+ employees or 50+FTE (seasonal workers) to provide insurance opportunity for their employees at low costs while avoiding federal penalties that may be applicable if no coverage is provided.