Health Maintenance Organization (HMO)
Typically, an HMO has lower premiums with more limited options for providers. This plan type requires an employee to use doctors in the network, and get a referral before seeing a specialist.
ResourcesSmall Business Health Care Hub
Evaluate your plan options
Selecting the right health insurance plan is essential for offering valuable group benefits to employees while ensuring financial stability. Thoughtful design is paramount.
Key considerations for evaluating your plan options
Coverage options
Access to essential services empowers a healthier, more productive workforce. Decide whether to extend services beyond standard Essential Health Benefits.
Cost-sharing strategies
Striking a balance in affordability for both employers and employees fosters financial well-being and helps maintain a stable budget.
Network selections
The right network choice ensures employees receive necessary care while keeping costs in check.
Understanding essential health benefits
Health insurance plans typically cover 10 essential categories, relevant to both individual and group plans. Additional services, such as adult dental, vision, weight management, or diabetes programs, may be available at an extra cost.
Essential health benefits include:
- Providers' services
- Hospital care
- Prescription drugs
- Maternity care
- Mental health services
- Emergency services
- Rehabilitative services
- Laboratory tests
- Preventive care
- Pediatric dental and vision insurance
Additional services may be available:
- Adult dental and vision insurance
- Weight management, including GLP-1's
- Diabetes management
- Telehealth
There are a few key components to consider when evaluating your plan options, including which services are covered, how costs are shared across you as an employer and your employees, and which doctors and hospitals are available in the plan.
Determining which services you will cover is a key step in ensuring your plan meets your employees’ needs.
When evaluating group plan options, it's important to look beyond just the monthly premium or employer contribution. To truly understand the value and affordability of a plan, consider the full spectrum of costs for employees, including premiums, deductibles, out-of-pocket cost limits, co-pays and coinsurance.
A crucial element of a health care plan is the network, which comprises the providers, hospitals and other health care professionals available to employees at pre-negotiated rates. Networks differ in their scope, including geographic coverage, types of services and providers covered, which can affect costs. Common network types include:
- Health Maintenance Organization (HMO)
- Point of Service (POS) plan
- Exclusive Provider Organization (EPO)
- Preferred Provider Organization (PPO)
Cost and provider options for common plan types
Lower cost Limited provider options
Point of Service (POS) Plan
Like an HMO, POS plans also require a referral from the person’s primary care doctor in order to see a specialist, but does cover some of the costs of out-of-network providers.
Exclusive Provider Organization (EPO)
EPOs cover only in-network doctors, but the network is generally larger than an HMO’s network. They may or may not require referrals for specialists.
Preferred Provider Organization (PPO)
Usually higher premiums than other types of provider network plans, a PPO pays for services both in and out of network. A person pays less if they use providers that belong to the plan’s network. Doctors, hospitals, and providers outside of the network can be seen for an additional cost without a referral.
Higher cost More provider options
Explore the network types and strategies that best suits your business needs.
Learn how to choose a provider networkBefore you choose a network type, find out what your employees actually need
Different employees have different priorities. Some value lower monthly premiums; others need access to specific doctors, specialists, or prescription drugs. Choosing a network type without employee input risks selecting a plan that doesn’t match actual usage patterns. Our one-page survey helps you gather this information before you commit to a plan design.
Download the Employee Needs Survey
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