What’s the Difference Between an HMO, EPO, and PPO?

In health insurance by Phillip Randazzo

What’s the Difference Between an HMO, EPO, and PPO?

Many consumers have questions regarding the types of health insurance policies available. On the individual market, there are three types:

HMO, EPO, and PPO

HMO, or health management organization, is a type of managed care organization (health plan) that provides health care coverage through a network of hospitals, doctors, and other health care providers. Typically, the HMO only pays for care that is provided by an in-network provider.

EPO, or exclusive provider organization, resembles an HMO in that covered health care is restricted to a defined set of health providers.  The insured must only use providers from the specified network of physicians and hospitals to receive coverage.  Typically, except for emergency situations, there is no coverage for care received from a non-network provider.

PPO, or preferred provider organization, contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

See the chart below to learn about the differences between these types of policies.

 

HMO EPO PPO
In-network coverage In-network coverage In- and out-of-network coverage
PCP referral required for specialist visits No PCP referral required for specialist visits No PCP referral required for specialist visits