HMO / PPO / EPO / POS

Updated: Oct 8

What's the difference?

All refer to the type of network available to the subscriber for health services. Here are the general differences as there may be variations depending on individual plans..

  • Health Maintenance Organization (HMO): This type of plan has a network of providers who work directly for or contract with the insurance plan that you can choose from for medical services. HMOs generally have little to no out-of-pocket expenses (except copayments) and subscribers must live in a certain geographic region (service area) to be eligible. Coverage outside the service area is not provided except in cases of emergency. HMOs require a primary care physician (PCP) and a referral before seeing a specialist. HMOs usually have lower premiums but are the least flexible.

  • Preferred Provider Organization (PPO): This type of plan is similar to a HMO in that it has preferred providers but it also expands care to out-of-network providers. Choosing to use a preferred provider is less costly than using an out-of-network provider where the PPO pays a reduced benefit. This type of plan does not require the use of a primary care physician (PCP) and do not require referrals to see a specialist. PPOs generally have highest premiums of all types of plans but offer the greatest flexibility.

  • Exclusive Provider Organization (EPO): This type of plan is similar to an HMO in that it has a network of providers and usually requires a primary care physician (PCP). It does not require a referral from your PCP to a specialist unlike an HMO. An EPO does not pay for services provided by an out-of-network provider except in the event of an emergency. EPOs premiums are usually higher than a HMO and offer a little more flexibility.

  • Point of Service (POS): This type of managed care plan is a hybrid between a HMO and PPO. You must choose a primary care physician (PCP) from the network and are required to get a referral to see a specialist whether in-network or out-of-network. Providers in a POS plan are not limited to a certain geographical area and are available out of state. With a POS plan you will have greater out-of-pocket costs if you choose to see an out-of-network provider. A POS plan offers more flexibility than a HMO or EPO but less than a PPO.

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