Choosing the right health insurance plan requires digging into the details. While it’s tempting to just look at the monthly cost, it’s best to dig into the details. One of the most important details is the type of plan. Knowing the difference in EPO vs PPO vs HMO plans is a vital step to choosing the right coverage. Learn more about these plan types and which might work best for you as you seek medical care, related health care services, etc. Yes, a health insurance company can give you access to a network of doctors, but various types of health insurance coverage handle your medical bills and the cost of care differently.
Key Points: EPO vs PPO vs HMO
- An EPO is a health insurance plan that doesn’t usually require referrals to see network specialists.
- A PPO has a network and will cover care outside the network for an additional cost.
- An HMO only covers in-network care and requires referrals to see a network specialist.
- HMOs are typically the least expensive option. PPOs are the most expensive, and EPOs are in the middle.
Best Health Insurance
- Best For:Nationwide coveragesecurely through Blue Cross Blue Shield Health Insurance's website
- Best For:No enrollment period health insurancesecurely through Sidecar Health Access Plan's website
Plans referred to above are excepted benefit fixed indemnity insurance products marketed and administered by Sidecar Health Insurance Solutions, LLC and underwritten by Sirius America Insurance Company or United States Fire Insurance Company, depending on the state. As an excepted benefit plan, it does not provide comprehensive/major medical expenses coverage, minimum essential coverage, or essential health benefits. You cannot receive a subsidy (premium tax credit and/or cost-sharing reduction) under the ACA in connection with your purchase of such an excepted benefit fixed indemnity insurance plan. Also, the termination or loss of this policy does not entitle you to a special enrollment period to purchase a health benefit plan that qualifies as minimum essential coverage outside of an open enrollment period. Coverage and plan options may vary or may not be available in all states.
What is Health Insurance?
Health insurance is a contract between you and an insurance company. You pay a monthly premium, and in return, the insurance company agrees to pay certain health care costs.
EPO vs PPO vs HMO: What’s the Difference?
Here, we'll go over the difference between each type of plan in greater detail.
What is an EPO Plan? (Exclusive Provider Organization)
An EPO has a network, which is made up of health care providers and facilities who have contracted with the insurance company. With an EPO, you must see providers within the network unless it’s an emergency. You may also need to choose a primary care physician, who will provide you with preventive care. Choosing this network doctor first helps unlock all the other services you receive.
What sets an EPO apart is that you don’t need a referral to see a specialist. You can go straight to the specialist if you need an appointment. An EPO may offer lower premiums than a PPO but higher premiums than an HMO, but it varies by plan.
What is a PPO Plan? (Preferred Provider Organization)
Like an EPO, a PPO has a network. PPOs allow you to visit out-of-network providers, but you pay more in healthcare costs than if you see in-network providers. You also don’t have to choose a primary care physician with a PPO, and you don’t need referrals to see a specialist.
PPOs have more flexibility and freedom than other plan types, and they also have higher premiums than HMOs and EPOs.
What is an HMO Plan? (Health Maintenance Organization)
HMOs are typically the most restrictive plan, in that you need to see in-network providers and get a referral before seeing a specialist. You’ll need to choose a primary care physician, and that physician will provide you with specialist referrals if needed. You can see out-of-network providers if there’s an emergency.
HMOs are typically less expensive than EPO and PPO plans.
How to Compare EPO vs PPO vs HMO Health Insurance Plans
It’s important to consider the details when you’re comparing health insurance plans. First, let’s define a few terms.
Important Terms to Know When Comparing Health Insurance Plans
Health insurance has a language all its own. Here’s what you need to know.
- Premium: Your premium is the amount you pay for your health insurance each month. If you purchase your plan through your state’s Health Insurance Marketplace, you may be eligible for tax subsidies that lower your premiums. If your plan is through an employer, the employer may cover some or all of the premiums.
- Deductible: This is the amount you pay for covered expenses before your health insurance plan starts paying.
- Annual out-of-pocket maximum: This is the most you’ll pay out-of-pocket for covered in-network services. Your plan may have a separate out-of-pocket maximum for out-of-network services.
- Coinsurance: This is the percentage you pay for covered services after you’ve met your deductible. For example, you might pay 20% for lab tests.
- Copayment: This is a set dollar amount you pay for a covered service. It often only applies after you’ve met your deductible. For example, you might pay $5 for a generic prescription.
- In-network: This is a health care provider or facility that is contracted with the insurance plan.
- Out-of-network: This is a health care provider or facility that isn’t contracted with the insurance plan.
What to Compare
Here’s what to compare:
- Network: Consider whether each plan is an EPO, PPO, or HMO and whether it’s important to you to be able to see out-of-network providers. Also, consider whether your current providers are in-network. If you don’t go to the doctor frequently, it may not be a big deal if you need to see a different physician for medical advice. If you have ongoing health conditions, you may prefer to stay with the same providers. In that case, confirm whether your providers belong to the network you’re considering.
- Out-of-pocket costs: It’s important to compare out-of-pocket costs. Compare deductibles, coinsurance, and copayments along with your annual out-of-pocket maximum.
- Premiums: Your monthly payment is an important factor, but it shouldn’t be the only one when you’re deciding on an insurance plan.
- Plan quality: If you’re buying a plan from your state’s Health Insurance Marketplace, many of the plans have quality ratings. If you’re buying a plan elsewhere, look the company up on the NCQA website. The NCQA measures the quality of health plans.
Factors that Affect Your Health Insurance Premium
Several factors affect your health insurance premiums.
- Location: The cost of living in an area also affects the cost of health care. State rules also have an impact.
- Age: Older people pay significantly more than younger people for health coverage.
- Tobacco use: Insurance companies can charge people who use tobacco more for insurance.
- Plan: The make-up of a plan can also affect premiums. If you pay more out-of-pocket with a higher deductible and higher out-of-pocket maximum, for example, your premiums will be lower. If you opt for a plan with lower out-of-pocket costs, your premiums will be higher.
By law, plans compliant with the Affordable Care Act (most health insurance plans) can’t charge more due to gender or medical history.
Health Insurance Insurance Provider Reviews
Here are top health insurance plans to consider.
1. Aetna
2. Cigna
3. Humana
4. UnitedHealthcare
5. Blue Cross Blue Shield
- Best For:Nationwide coveragesecurely through Blue Cross Blue Shield Health Insurance's website
Is an EPO vs PPO vs HMO Plan Best for You?
Choosing the right health insurance plan involves more than just whether it’s an EPO, HMO or PPO, but that’s an important part of the decision. Now that you know the difference when comparing EPO vs HMO vs PPO plans, you're set to begin your search. Look at all aspects of the plan and how it fits into your budget and your health needs. If you need more information, check out more of Benzinga’s insurance articles.
Frequently Asked Questions: EPO vs PPO vs HMO Plans
Q. What does EPO stand for in health insurance?
An EPO is an exclusive provider organization. It’s a type of plan that has a network, and you can’t seek out-of-network care unless it’s an emergency. It typically requires plan members to have a primary care physician, and you don’t usually need referrals to see a specialist.
What does PPO stand for in health insurance?
A PPO is a preferred provider organization. This type of plan has a network, but you can seek care from providers outside the network for an additional cost. You also don’t need referrals to see a specialist or a primary care physician.
What is the difference between PPO and HMO in insurance?
Both PPOs and HMOs have a network. HMOs don’t pay for care outside the network unless it’s an emergency. PPOs will pay for out-of-network care, but it costs more. HMOs often require you to get a referral before seeing a specialist, while PPOs don’t. HMOs are also less expensive than PPOs.