HMO, PPO, EPO, POS -- what do these letters mean and what do they mean for your family’s medical care? Before choosing a health insurance plan for yourself or your family, take a moment to explore the different plan types.
There are two main types of plans: HMOs and PPOs. There are also POS plans and EPO plans, options that combine some desirable aspects of HMOs and PPOs.
The chart below compares these 4 types of plans. Keep in mind that health plan details vary from state to state and between different insurance carriers. This post is a general overview of what each plan type offers, but it’s still important to read through the Summary of Benefits for each plan you are interested in.
First take a look at the plan types available to you in your area, then read on to learn more about the primary advantages of each plan type.
|Will the plan:|
|Cover out-of-network care?||Require a Primary Care Physician?||Require a referral for specialist care?|
Health Maintenance Organization
Point of Service
Preferred Provider Organization
Exclusive Provider Organization
HMO Key Notes:
A Health Maintenance Organization (HMO) gives you access to medical providers and hospitals in its select network. The network is a collection of medical providers and facilities that have met the standards of the insurance company and have agreed to reduce rates for network members. Medical coverage is restricted to providers who are in-network. If you visit a doctor or hospital out-of-network, your insurance company will not cover any medical expenses.
As a HMO member, you will choose a Primary Care Physician or “gatekeeper” who will refer you to specialist doctors (i.e. Cardiologist, Dermatologist, Pathologist, etc.). Your Primary Care Physician serves as your health advocate -- someone who will check to see what medical issues you have and refer you to appropriate specialized care providers. This way, you can be sure that you are visiting the right type of doctor every time you have a medical issue.
The HMO is a good choice if you:
- Would like a central doctor who will serve as a coordinator for specialist care
- Are not tied to particular doctors that are out of the HMO network
- Do not often need to seek medical care out of town
- Are looking for the most affordable monthly premium within a certain insurance company
POS Key Notes:
A Point of Service (POS) plan uses a Primary Care Physician to refer you to in-network and out-of-network doctors. It will normally cost more to see out-of-network doctors. This type of plan is considered a HMO plan with more out-of-network coverage.
The POS is a good choice if you:
- Would like a Primary Care Physician to coordinate your specialist care
- Would like the option of seeking out-of-network care
PPO Key Notes:
With a Preferred Provider Organization (PPO), you have more flexibility in choosing a doctor or hospital. Like an HMO, a PPO has a network of doctors that will be covered under your plan’s benefits. You can also see doctors outside of the PPO network, but you may have to pay more for these visits. There is no mandatory Primary Care Provider and you can see specialists that you pick yourself without needing a referral.
The PPO is a good choice if you:
- Are often out of your provider’s area of medical coverage
- Desire more flexibility when selecting specialists
- Want to continue seeing a doctor who is outside of all available networks
EPO Key Notes:
An Exclusive Provider Organization (EPO) has a network of doctors and hospitals that are used exclusively. You will not need a Primary Care Physician to refer you to specialist care. In this sense, an EPO is similar to a PPO but with a more limited network. If you go outside of the network then your expenses will not be covered by your EPO plan.
The EPO is a good choice if you:
- Prefer choosing and visiting specialist doctors freely
- Are comfortable seeking care in a close-knit network of providers
- Do not often need to seek medical care when out of town