Overview
- HMO = Health Maintenance Organization: HMOs tend to have lower monthly premiums and lower cost-sharing than plans with fewer network restrictions, but they require primary care provider (PCP) referrals and won’t pay for care out-of-network except in emergencies.
- PPO = Preferred Provider Organization: PPOs got that name because they have a network of providers they prefer that you use, but they’ll still pay for out-of-network care. Given that they’re less restrictive than most other plan types, they tend to have higher monthly premiums and sometimes require higher cost-sharing. PPOs have lost some of their popularity in recent years as health plans reduce the size of their provider networks and increasingly switch to EPOs and HMOs in an effort to control costs. PPOs are still common among employer-sponsored health plans but have disappeared altogether in the individual insurance market in some states (individual insurance is the kind you buy on your own—including through the exchange in your state—as opposed to obtaining from an employer)
- EPO = Exclusive Provider Organization: EPOs got that name because they have a network of providers they use exclusively. You must stick to providers on that list or the EPO won’t pay. However, an EPO generally won't make you get a referral from a primary care physician in order to visit a specialist. Think of an EPO as similar to a PPO but without coverage for out-of-network care.
- POS = Point of Service: POS plans resemble HMOs but are less restrictive in that you’re allowed, under certain circumstances, to get care out-of-network as you would with a PPO. Like HMOs, many POS plans require you to have a PCP referral for all care whether it’s in or out-of-network.
Points of Differentiation
The six basic ways HMOs, PPOs, EPOs and POS plans differ are:- Whether or not you’re required to have a primary care physician (PCP)
- Whether or not you’re required to have a referral to see a specialist or get other services
- Whether or not you must have health care services pre-authorized
- Whether or not the health plan will pay for the care you get outside of its provider network
- How much cost-sharing you’re responsible for paying when you use your health insurance
- Whether or not you have to file insurance claims and do paperwork
https://www.verywellhealth.com/hmo-ppo-epo-pos-whats-the-difference-1738615
How Plans Compare
Health insurance regulations vary from state to state and sometimes a plan won’t stick rigidly to a typical plan design. Use this table as a general guide, but read the fine print on the Summary of Benefits and Coverage for each plan you’re considering before you enroll. That way you’ll know for sure what each plan will expect from you, and what you can expect from it.Physician Requirement