HMO / PPO / EPO / POS
Updated: Oct 8, 2022
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.
