Insurance Plans

HMO, POS, PPO, EPO and HDHP with HSA: What’s the difference?

Whether you are signing up for insurance through open enrollment for Medicare, ACA marketplace plans, or your employer, please be aware of the following very critical health insurance terms which may impact your primary care options.

First, there are two basic types of plans, an HMO and a PPO.

• Health Maintenance Organization (HMO) – HMO’s are the most affordable of insurance plans and typically have copayments for doctors visits, however they have very limited or strict requirements including very narrow networks and no out of network benefits. If you have an HMO plan, you MUST have a PCP assigned, and you are required to see that PCP. If Carolina Family Healthcare or one of our providers are not your assigned PCP, we cannot bill your insurance and you may have to pay out of pocket for your visit.
• Preferred Provider Organization (PP0) – PPO’s have higher premiums than other plans, however you are not required to have an assigned PCP, although one is recommended. In addition, you can see specialists without a referral from your PCP, and the PPO has out-of-network benefits. Be aware that, when using out-of-network benefits, you may have a higher copay, deductible and/or coinsurance than when you see an in-network (participating) provider.

Next, there are other plans that are a hybrid of HMOs and PPOs, which includes POS and EPO plans. These plans vary by insurance company, so please read the requirements carefully when signing up for these plans. Most Point of Service (POS) plans require you to have an assigned PCP who has to refer you to specialists, but they usually have out-of-network benefits. Exclusive Provider Organization (EPO) plans usually don’t require an assigned PCP, however you must see a PCP in order to get a referral to specialists, and they don’t have out-of-network benefits.

Finally, many employers offer a High Deductible Health Plan (HDHP) which has low premiums, but higher upfront out-of-pocket costs through a high deductible. With the exception of preventive services for ACA compliant plans, HDHP plans require each insured to pay the deductible before the insurance begins to pay for services. These high deductibles can range from $2,000 to $10,000 per individual. Employers often pair an HDHP with an Health Savings Account (HSA) to help cover some or all of the deductible. An HDHP can be an HMO, PPO, POS, or EPO.

The following is a summary of the 4 types of plans. Please keep in mind that the POS and EPO may actually have different benefits than shown in the table as each insurer has different definitions of these plans.

Please keep in mind that, regardless of what type plan you select, it is always a good idea to assign Carolina Family Healthcare as your primary care provider, including PPO plans. Having your PCP selected will allow the timely and accurate transfer of your medical records to our providers.

Medicare Open Enrollment

October 15 to December 7

Medicare open enrollment runs from October 15th to December 7th. For 2025, Carolina Family Healthcare will participate with the following Medicare plans:

• Traditional Medicare Part B – we recommend that you have a supplement plan to help cover the deducible and 20% coinsurance.
• Aetna Medicare Advantage
• Blue Medicare of NC
• HealthTeam Advantage – This is a newer plan now available in the Charlotte market that is limited to Novant Health Clinically Integrated Network, of which CFH is a member.
• United Healthcare AARP Medicare Advantage

Carolina Family Healthcare will NOT be participating with the following Medicare plans in 2025. If you continue with one of these plans, please select the PPO option in order to continue with our office.

• Cigna Medicare
• Humana Medicare
• Devoted Medicare
• Wellcare Medicare
• Any HMO plans not based in North Carolina

ACA Marketplace Open Enrollment

November 1 to January 15

If you purchase an ACA plan through the marketplace, please keep in mind that many of these plans are very narrow networks with very limited participation. Open enrollmenet for the ACA plans runs from November 1, 2024 to January 15, 2025.

For 2025, Carolina Family Healthcare will participate in the following ACA Marketplace plans:

• Blue Home through BCBSNC
• Blue Options through BCBSNC
• Care Source (new marketplace plan available in the Charlotte area)
• Cigna
• UHC Community Care (ACA plans only, not Medicaid)

Carolina Family Healthcare will NOT be participating with the following ACA plans:

• Aetna/CVS
• Ambetter
• AmeriHealth
• Blue HPN
• Blue Local
• Humana
• Wellcare

BCBS of South Carolina Blue Essentials for individuals

State of NC Employees

In 2025, the state of NC employees will change insurance coverage from BCBSNC to Aetna, of which Carolina Family Healthcare will be participating.

You will need to reselect your PCP with Aetna in order to get $0 copay.

When being seen for the first time in 2025, please make sure that you bring a copy of your new insurance card with you in order to ensure you don’t receive any unnecessary bills.

Employer Open Enrollment

Many large employers also have open enrollment that typically runs until the beginning of December. Please keep in mind the following when selecting your plan in order to prevent any disruptions in care during 2025.

• BCBS HPN plans – Many employers are now offering the BCBS Blue HPN network as a lower cost alternative. These plans are narrow networks limited to Atrium facilities and providers only, therefore CFH is NOT in network. Employers offering BCBS HPN include Wells Fargo and the Compass Group.

In 2025, Carolina Family Healthcare will participate with the following commercial insurances:

• Aetna including First Health
• BCBS (excluding Blue HPN)
• Cigna including Great West Healthcare
• United Healthcare including United Medical Resources

CFH will NOT be participating with the following commercial insurances:

• Humana
• Medcost
• Multi-Plan

Please remember to select a PCP regardless of

the type of plan and insurance payer