HMO vs. PPO vs. EPO explained

The short answer

HMOs and EPOs only cover in-network care except emergencies, and HMOs usually need referrals to see specialists. PPOs cover out-of-network care at a higher cost and don't require referrals, but have higher premiums. The right choice depends on whether your doctors are in the network and how much flexibility you need.

Key takeaways

HMO plans usually require a primary care doctor and referrals, and don't cover out-of-network care except emergencies.

EPO plans don't require referrals but also don't cover out-of-network care.

PPO plans cover out-of-network care at a higher cost and usually have higher premiums.

Always check that your doctors, hospital and prescriptions are in the plan's network before enrolling.

Two plans can have the same deductible and copays and still feel completely different to use. The difference is usually the network: which doctors and hospitals the plan works with, and what happens if you go outside it.

In-network vs. out-of-network

In-network providers have a contract with your plan and agree to accept its negotiated price, the allowed amount. Out-of-network providers don't. Depending on your plan, out-of-network care might cost much more, or not be covered at all. HealthCare.gov's guide to plan types has the official definitions.

The four common plan types

Plan type	Need a primary care doctor?	Referrals for specialists?	Out-of-network coverage?
HMO	Usually yes	Usually yes	No, except emergencies
EPO	Usually no	Usually no	No, except emergencies
PPO	No	No	Yes, at a higher cost
POS	Yes	Yes	Yes, at a higher cost

HMO: lower cost, more structure

A health maintenance organization coordinates care through your primary care doctor. It's usually the most affordable option if you're happy with the doctors in the network.

EPO: no referrals, but stay in network

An exclusive provider organization lets you see in-network specialists directly, without referrals, but it won't pay for non-emergency out-of-network care.

PPO: the most flexibility

A preferred provider organization lets you see anyone, with lower costs in-network. It suits people who travel, live in two places, or want to keep a specific out-of-network doctor. Note that out-of-network providers can bill you for amounts above what the plan pays, called balance billing.

The federal No Surprises Act protects you from most surprise out-of-network bills for emergency care and for some care at in-network hospitals and surgery centers (CMS: your rights against surprise medical bills). If an out-of-network bill arrives anyway, compare it with your explanation of benefits before paying.

How to choose

List your must-keep doctors, hospitals and pharmacies.
Search each plan's provider directory, and call the doctor's office to confirm they take that specific plan.
Check how often you see specialists. Frequent specialist care makes referral rules matter more.
Compare premiums and out-of-pocket maximums together, not separately.

If you're shopping on the Marketplace, every plan lists its network type, so you can filter by it during open enrollment.

For the cost terms, see how health insurance works.

Frequently asked questions

Are emergencies covered out-of-network?

Yes. Emergency care must be covered at in-network cost-sharing, and the No Surprises Act protects you from most surprise out-of-network bills for emergencies and for some care at in-network facilities.

Which is cheaper, an HMO or a PPO?

HMOs usually have lower premiums and lower costs when you stay in network. PPOs cost more each month in exchange for flexibility to see out-of-network providers.

What is a POS plan?

A point-of-service plan blends HMO and PPO features: you pick a primary care doctor and need referrals, but you can go out of network at a higher cost.

This article is general education, not advice for your situation. Coverage depends on your state, your plan or policy, and the plan year. When in doubt, check your plan or policy documents or ask a licensed agent. Full disclaimer.