HMO, PPO, EPO or POS: Which Plan Type Is Right for You?

HMO, PPO, EPO and POS are network types. They decide three things: whether you need a primary care physician (PCP), whether you need a referral to see a specialist, and whether the plan pays anything when you see a doctor outside its network. Here is how they compare and how to pick.

The four plan types side by side

These are general rules. Plan names are not standardized, so some plans labeled HMO do not require referrals. Always check the plan's Summary of Benefits and Coverage (SBC) before you enroll.

HMO: Health Maintenance Organization

An HMO covers care only from doctors and hospitals in its network, except in an emergency. You usually choose a primary care physician who handles routine care and refers you to in-network specialists. If you see an out-of-network provider for non-emergency care, the plan generally pays nothing. More on HMOs.

PPO: Preferred Provider Organization

A PPO lets you see any provider without a referral. You pay less in network, and the plan still pays part of the cost out of network, usually after a separate, higher out-of-network deductible. PPOs usually have the highest premiums. HMO vs PPO compared.

EPO: Exclusive Provider Organization

An EPO covers only in-network care, except emergencies, like an HMO. Unlike most HMOs, you usually do not need a primary care physician or referrals, so you can book directly with any in-network specialist. More on EPOs.

POS: Point of Service

A POS plan works like an HMO in network: you usually have a primary care physician, and in-network specialists need a referral. The difference is that a POS plan also pays part of the cost when you go out of network, after a separate, higher out-of-network deductible. You may need to pay the provider up front and file the claim yourself, and out-of-network providers can bill you above what the plan allows. More on POS plans.

Which plan type fits you?

• HMO if your doctors and hospital are all in the network and keeping the premium low matters most.
• EPO if your doctors are all in the network and you want to see specialists without a referral.
• POS if you want HMO-style pricing but need some coverage for a doctor outside the network, or someone in your household spends part of the year away from home.
• PPO if you want the most freedom to see any provider and can afford a higher premium.

Which types are sold depends on your state and county. Some carriers sell only HMOs and POS plans in the individual market. A licensed agent can show you what is available where you live.

Protections that apply to every plan type

• Emergencies: ACA plans must cover emergency care at in-network cost sharing, without prior approval, even at an out-of-network emergency room.
• Surprise bills: The federal No Surprises Act protects you from most surprise out-of-network bills for emergency care and for certain care at an in-network hospital or surgery center.
• Direct access: You can see an in-network OB/GYN without a referral, and you can choose an in-network pediatrician as your child's primary care physician.

How to check whether your doctor is in a plan's network

1. Find the exact network name on the plan's Summary of Benefits and Coverage. One carrier can sell several networks under the same brand.
2. Search that network in the carrier's online provider finder for each doctor, specialist and hospital you use.
3. Check that each prescription you take is on the plan's drug list.
4. Call the doctor's office to confirm they accept that specific plan for the coming year.

We are happy to check your doctors and prescriptions for you before you enroll.

Common questions

Is an HMO or EPO a good choice for a college student who lives out of state?
Usually not. HMOs and EPOs cover only emergencies outside their network, so routine visits near campus may not be covered. A POS or PPO plan, or a student health plan, is often a better fit.

Is a POS plan always more expensive than an HMO?
No. Premiums depend on the network, metal tier, your age and where you live. In some areas a POS plan has the lowest premium in its tier, so compare plans for your own ZIP code.

Does it cost more to enroll through an agent?
No. Premiums are the same whether you enroll directly, through the marketplace or with a licensed agent.

Plan rules vary by carrier and plan, and the Summary of Benefits and Coverage and policy for each plan govern. Questions? Call 855.847.7020 or email help@ihealthagents.com. Our help is free.