Real answers for your healthcare questions

What is the difference between an HMO, PPO, and EPO health plan?

Answer

HMO, PPO, and EPO plans mainly differ in how they use provider networks and referrals. An HMO is usually more network focused, a PPO generally offers more out of network flexibility, and an EPO usually requires in network care except for emergencies.

What to Know

HMOs may require you to select a primary care doctor and get referrals for some specialists. PPOs commonly allow you to see specialists without referrals and may cover out of network care at a higher cost. EPOs can offer direct specialist access while still limiting routine coverage to the network.

What to Do Next

Check the actual plan rather than relying only on the label. Compare your doctors, hospitals, referral rules, out of network benefits, and total cost because plan designs can vary.

Agent Perspectives

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Liz Michel Verified Licensed

Independent Health Insurance BrokerMcKinney, TX

Well, in order of best to worst, PPO - offers nationwide coverage, larger pool of doctors/specialists/hospitals in network, no referral needed for specialist. EPO - offers only in network coverage, no out of network. Usually fine for clients in metro areas, no referral needed for specialist. HMO - smaller network, fewer doctors/providers are in network and will accept an HMO plan, will need to see your primary care dr for a referral to a specialist, only offers mostly localized (in state) coverage.

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