HMO vs. PPO vs. EPO Plans: What’s the Difference?
There are different types of health insurance plans, and it’s important to find the right fit for your needs because plans can vary in cost, coverage, and the networks you can use to get care. Learning the basics of how common plan types work is a good first step. Here’s a quick summary of HMO vs. PPO vs. EPO to get you started.
Health maintenance organization (HMO) plans focus on preventive care and wellness. Your primary care provider (PCP) will coordinate your care—keeping everything connected—and they will give you a referral if you want to see certain specialists.
Preferred provider organization (PPO) plans are more flexible. You can go out-of-network to get care, but these plans can be more costly than others.
Exclusive provider organization (EPO) plans are budget-friendly, but you can’t go out-of-network to get care (except for emergencies). If you choose this type of plan, you need go to in-network doctors and hospitals for all nonemergency services.
What is an HMO Health Insurance Plan?
A health maintenance organization (HMO) plan is often more limited when it comes to the health care providers you can see. This type of plan offers you a network of doctors and hospitals to choose from when you need care. You must choose a primary care provider (PCP) who is in your HMO network to coordinate your care. Your PCP will need to give you a referral if you want to see certain specialists.
What is a PPO Health Insurance Plan?
A preferred provider organization (PPO) plan gives you more flexibility in terms of which health care providers you can see. You can choose from a larger network of doctors and hospitals than with other types of plans. A PPO plan even gives you leeway to see out-of-network doctors, although you will pay more out-of-pocket if you do.
The freedom of choice that a PPO plan provides may also cost you more when it comes to your premium.
What is an EPO Health Insurance Plan?
An exclusive provider organization (EPO) plan gives you access to a local network of doctors and hospitals. While you can usually choose from many providers for medical services without a referral, you must stay in your network (except in the case of emergency services). This can be a positive for people who like simplicity. You don’t have to worry about different networks with this type of plan, so managing your care can be easier.
Which Plan is Best for Your Needs?
Is an HMO Plan Right for Me?
HMOs tend to have less flexible networks, but they are generally considered reasonably priced and can be a good option to help you get a plan within your budget.
Is a PPO plan right for me?
A PPO plan might be a good option if budget is not your main concern. This type of plan gives you access to a larger network of doctors and hospitals and more freedom to choose which health care providers you see. This flexibility comes with a trade-off—higher monthly premiums.
Is an EPO plan right for me?
An EPO plan can be a good choice if you need to stay within a budget and are OK with choosing from a limited number of health care providers.
Additional Questions to Consider About HMO, PPO, and EPO Plans
Is a PPO plan worth the higher cost?
That depends on what matters most to you: access or affordability. PPO plans usually have higher premiums and out-of-pocket costs because they give you the flexibility to get care from out-of-network health care providers. If having access to a larger network of doctors and hospitals is important to you, the extra costs might be worth it.
Will an HMO suit me if I travel frequently?
If you travel often, an HMO plan probably isn’t ideal for you. This type of plan typically requires you to get all your care from in-network providers, unless you have an emergency. If you need more flexibility because you take a lot of trips, you might want to consider other plan types. An HMO plan can be a good option if you get all your care near where you live or from your PCP.
Should I get an EPO or HMO?
It all comes down to your budget and how much flexibility and control you want. Both types of plans are generally considered budget friendly and offer limited networks, but they differ in how referrals work. HMO plans require you to select a PCP who will provide referrals for you to see specialists. If you want the ability to self-refer to a specialist, an EPO plan might work better for you.
Are EPO plans good for families?
An EPO plan can be a good fit for families that want a budget-friendly option and are OK with using a local network of care providers (except for emergencies). You can self-refer to specialists if you choose an EPO plan, which offers some level of flexibility.
What will happen If I go out-of-network on an EPO plan?
Under an EPO plan, you will likely face higher out-of-pocket costs if you go to a doctor or hospital that is out-of-network (unless you are experiencing an emergency).
Do any of these plans cover specialists without referrals?
Yes. You can self-refer to a specialist if you select an EPO or PPO plan. HMO plans require you to get a referral from your PCP for specialty care.
Find the Right Insurance Plan with UPMC Health Plan
Now that you’ve explored your options, it’s time to take the next step. You don’t have to navigate it alone. You can work with us one-on-one to find the plan that’s right for you. Call 1-833-512-2833 (TTY: 711) or visit upmchealthplan.com/marketplace today!