The side-by-side
| HMO | EPO | PPO | |
|---|---|---|---|
| Primary care doctor required | Usually | Usually not | No |
| Referrals to see specialists | Usually | Usually not | No |
| Out-of-network care (non-emergency) | Not covered | Not covered | Covered, at a higher cost |
| Emergency care anywhere | Covered | Covered | Covered |
| Typical premium | Lowest | Middle | Highest |
| Best for | Staying local, saving money | Local care, no referrals | Travel, specialists, flexibility |
HMO: the budget pick, if you stay close to home
A Health Maintenance Organization keeps costs down by keeping you inside its network. You pick a primary care doctor who coordinates your care and refers you to specialists. If you go outside the network for non-emergency care, you usually pay the whole bill.
Choose an HMO if your doctors are in the network, you're home most nights and you don't mind getting referrals.
EPO: no referrals, but stay in the network
An Exclusive Provider Organization is a middle ground. You can usually see in-network specialists directly, but out-of-network care isn't covered except emergencies. EPO networks can be large or small, so check yours.
Choose an EPO if you want to skip referrals and the network includes the hospitals and specialists you care about.
PPO: the most freedom, at a price
A Preferred Provider Organization lets you see any doctor, in or out of network, without a referral. In-network care costs less; out-of-network care is covered at a higher share, often with a separate deductible, and providers can bill you the difference between their charge and what the plan pays.
Choose a PPO if you travel for work (truck drivers, travel nurses, consultants), split time between states, have kids at college out of state, or want access to specific specialists or academic medical centers.
Why PPOs can be hard to find
In many states, individual-market plans sold on the Marketplace are mostly HMOs and EPOs, because narrow networks keep premiums down. That doesn't mean you're out of luck. PPOs may be available from a smaller number of carriers, off-exchange, through some employer plans, or through private underwritten plans for healthy applicants. It's one of the most common reasons people come to us.
Don't choose on the label alone
Two HMOs can be wildly different. Before you enroll, check:
- Your doctors and hospital by name in the carrier's directory, and call the office to confirm.
- Your prescriptions on the plan's drug list (formulary), and the tier.
- The out-of-pocket maximum, the most you'd pay in a bad year.
- Out-of-area rules for urgent care and follow-up visits if you travel.
Frequently asked questions
Is a PPO better than an HMO?
Not always. A PPO gives more freedom but usually costs more. An HMO can be the better value if your doctors are in-network and you rarely travel.
What's the difference between an EPO and a PPO?
Both usually skip referrals. A PPO pays for some out-of-network care; an EPO generally doesn't, except emergencies.
Why are PPO plans hard to find on the Marketplace?
Many carriers sell mostly HMO and EPO plans on the individual market to control cost. PPOs may be available from fewer carriers, off-exchange or privately.
Looking for a PPO in your state?
We'll show you which PPO and broad-network options are actually available to you.
Get a QuoteGeneral information only. Plan designs vary by carrier and state. Always review the plan's Summary of Benefits and Coverage before enrolling.