Health Insurance

What are the differences between an HMO, PPO, EPO, and POS plan?

What you need to know

All health insurance plans will have a network of health providers you’ll have access to. (If you have a medical emergency, your plan will usually cover most of your charges if you’re seen by an out-of-network provider.) How you access that network will depend on the type of plan you’re on:

PPO (Preferred Provider Organization)
This plan type lets you see any provider you want. You have two options: see the providers contracted to the plan at a lower cost (a.k.a. in-network), or see providers not contracted to the plan at a higher cost (a.k.a. out-of-network). Unlike an HMO, you don’t have to get a referral from a primary care doctor to see a specialist.

Typically, you’ll have a higher deductible and out of pocket maximum when you see out-of-network providers, but you’ll have the ability to see any doctor or hospital you want and still have your claims paid.

For example:

You have a mole on your arm that occasionally inflames and falls off. Someone says you should have it looked at. Instead of seeing your primary care physician, you want to go to the dermatologist. You can call up any dermatologist and schedule an appointment – no referrals needed.

But, the dermatologist you want to see doesn’t take your insurance. No worries, book the appointment, pay the dermatologist and send a claim to your insurance company. They’ll apply what you paid to your out-of-network deductible and/or reimburse you up to 100% of what you pay that exceeds your normal copay or coinsurance.

EPO (Exclusive Provider Organization)
This plan type is like the PPO, except you’re not covered if you go out-of-network. However, you can still go directly to a specialist, bypassing the need for a referral from your primary care physician.

HMO (Health Maintenance Organization)
This plan type only allows you to see providers that are directly contracted to the plan. You’ll have a primary care physician, and that physician coordinates your care and will refer you to specialists that are directly contracted to your plan.

For example:

You’re on an HMO plan with BestCare Insurance. You been having shoulder pain that your primary care physician has treated, but it hasn’t improved. You want to see an orthopedist. For that to happen, your doctor writes you a referral to a BestCare orthopedist, and BestCare will cover the visit. If you go to an orthopedist that is not on the BestCare HMO network, you’ll pay that orthopedist’s fees on your own, as BestCare will not reimburse you.

POS (Point of Service Plan)
This plan type is a hybrid of the HMO and PPO plans. You’ll have a primary care provider on the HMO network that can coordinate your care, or you can see doctors on the PPO network or out-of-network. The HMO network will have the lowest deductible and copays, and you’ll need referrals from an HMO doctor to see specialists in the HMO network, or pay HMO copays when seeing PPO specialists.

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