HMO Vs PPO Vs EPO Insurance – Which insurance Plan Should You Choose? Choosing your health insurance plan is not a decision that you should make lightly. There are numerous types of plans that may sound similar but differ in their coverage options. Exclusive Provider Organizations (EPOs) and Preferred Provider Organizations (PPOs) are two such health plans that offer distinct benefits.
In order to choose the best health insurance for you and your family, you have to understand the difference between an HMO, PPO, EPO, and POS health plan. Those are acronyms for the different types of managed care plans available in most areas. Take the time to understand each type of health plan so that you can determine whether EPO or PPO insurance is best for your unique needs.
What is EPO Insurance Plan?
EPO stands for “Exclusive Provider Organization” plan. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no out-of-network benefits. An EPO is usually more pocket-friendly than a PPO plan. However, if you choose to get care outside of your plan’s network, it usually will not be covered (except in an emergency). If you’re looking for lower monthly premiums and are willing to pay a higher deductible when you need health care, you may want to consider an EPO plan.
EPO Insurance Plan Summary
- Exclusive Provider Organization (EPO) health plans are similar to Health Maintenance Organizations (HMOs) as they do not cover care outside of the plan’s provider network.
- With an EPO plan, you do not always need a referral to see a specialist.
- EPO health plans are often more affordable than PPO plans if you choose a doctor or specialist in your local network.
- If you choose to get care out of your plan’s network, your medical care may not be covered.
- In emergencies are often covered even if they are out of your network.
- An EPO plans limit a patient’s access to a targeted group of providers within a network.
- With an EPO insurance plan, you will have lower monthly premium payments.
Bottom Line on EPO Health Insurance
EPOs have some traits in common with HMOs and some traits in common with PPOs. As such, you might consider an EPO to be a cross-breed between an HMO and a PPO: Like an HMO, you have to stay within the plan’s network. But like a PPO, you’re usually not required to get a referral from your premium care doctor to see a specialist.
What is a PPO Insurance Plan?
PPO, an acronym for Preferred Provider Organization, is a type of health plan that offers a larger network so you have more doctors and hospitals to choose from. Preferred Provider Organization (PPO) is similar to an HMO as it offers a network of healthcare providers patients can use for their medical care. Your out-of-pocket costs are usually higher with a PPO insurance plan than with an HMO or EPO plan.
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PPO Insurance Plan Summary
- PPO Insurance is one of the most popular types of health plans as it allows you to visit whatever in-network health provider you wish without having to get a referral from your primary care physician.
- PPO insurance allows you the freedom to receive care from any health provider, in or out of your network, unlike HMO and EPO plans.
- PPO insurance also does not require you to choose a Primary Care Physician (PCP). Therefore, if you already have a doctor that you like, you do not need to switch if you prefer not to.
- PPO plans do not require referrals. You have the option to see a specialist without first having to consult your PCP.
- PPO plan comes with more freedoms at a higher cost. Expect to pay higher out-of-pocket costs with PPO insurance plans in comparison to EPO and similar plans.
- You can reduce your costs by choosing an in-network provider who is part of your PPO network.
- If you’re willing to pay a higher monthly premium to get more choice and flexibility in choosing your physician and health care options, you may want to choose a PPO health plan.
What is an HMO Insurance Plan?
An HMO, “Health Maintenance Organization,” is a type of health plan that offers a local network of doctors and hospitals for you to choose from. It usually has lower monthly premiums than a PPO or an EPO health plan. An HMO may be right for you if you’re comfortable choosing a primary care provider (PCP) to coordinate your health care and are willing to pay a higher deductible to get a lower monthly health insurance premium.
What are the main differences between HMO, PPO, and EPO plans?
|PCP Required||Yes||No||Often, not always|
|Out-of-Network Coverage||For medical emergencies only||Yes, at a higher cost||For medical emergencies only|
What’s the difference between in-network coverage and out-of-network coverage?
Each time you seek medical care, you can choose your doctor. You have the choice between an in-network and out-of-network doctor. When you visit an in-network doctor, you get in-network coverage and will have lower out-of-pocket costs. That’s because participating health care providers have agreed to charge lower fees, and plans typically cover a larger share of the charges. If you choose to visit a doctor outside of the plan’s network, your out-of-pocket costs will typically be higher or your visit may not be covered.
HMO, PPO, And EPO, Which Is Best?
It depends on how comfortable you are with restrictions and how much you’re willing to pay. The more a health plan limits your freedom of choice, for instance, by not paying for out-of-network care or by requiring you to have a referral from your doctor before you see a specialist, the less it will generally cost in premiums and in cost-sharing.
The more freedom of choice the plan permits, the more you’re likely to pay for that freedom. Your job is to find the balance you’re most comfortable with.
If you want to keep your costs low and don’t mind the restrictions of having to stay in-network and having to get permission from your PCP to see a specialist, then perhaps an HMO is for you.
If you want to keep costs low, but it irks you to have to get a referral for a specialist, consider an EPO (keeping in mind that some EPOs do require PCPs and referrals; always check the details of the plan you’re considering).
If you don’t mind paying more, both in monthly premiums and cost-sharing, a PPO will give you both the flexibility to go out-of-network and to see specialists without a referral. But, PPOs come with the extra work of having to get pre-authorization from the insurer for expensive services, and they tend to be the most expensive option.
If you’re buying your own coverage (as opposed to getting it from your employer), you may not have any PPO options, as individual market plans have increasingly switched to the HMO or EPO model.
And if you’re getting coverage from your employer, the scope of your plan options will generally depend on the size of your employer. Bigger employers tend to offer more plan options, whereas a small employer might just have a single plan available for employees to accept or decline.