EPO vs. PPO vs. HMO – Which Is Best for You?

Choosing a health insurance plan can seem daunting with so many options to choose from. We're here to help! This guide breaks down Exclusive Provider Organization (EPO), Preferred Provider Organization (PPO), and Health Maintenance Organization (HMO) to help you determine which is right for you.

What Is a Health Maintenance Organization (HMO)?

If you enroll in an HMO your costs — copay, premium, and deductibles — will be lower than an EPO or PPO, but you will need to see your primary care physician (PCP) for each non-emergency health problem, except for preventive care. Your PCP will decide whether to refer you to a specialist. Also, you are limited to in-network providers. Out-of-network care is usually not covered.

How Does an HMO Work?

In an HMO, your primary care doctor (PCP) is your main point of contact, and the person you see first when you need care. If your PCP decides you should see a specialist, they can refer you to one who is in-network. A specialist visit without that referral may not be covered.

One exception is preventive care. If you visit a provider in the HMO's network, you usually will not need a referral for a preventive mammogram, colonoscopy, routine bloodwork, and other care the health plan agrees is appropriate for your age.

This means that if your shoulder gets sore after a weekend playing baseball, though you may think an orthopedist visit is in order, you first need to schedule an appointment with your PCP. If the PCP believes an orthopedist or other specialist is needed to treat your shoulder, they will give you a referral to an in-network orthopedist.

Is an HMO a Good Option for You?

You may want to consider enrolling in this type of plan if:

• You are looking to pay lower premiums, copays, and deductibles than other types of plans.
• You like the idea of having your PCP function as “command central" for your healthcare, and do not mind needing referrals to see specialists.
• You do not think you will need to use out-of-network health care professionals.

What is an Exclusive Provider Organization (EPO)?

An EPO insurance plan allows members the flexibility to see in-network health care providers without getting pre-approval from their primary care physicians (PCP). Also, emergency visits to out-of-network providers are usually covered, though likely with a higher copay than an in-network provider. This can be invaluable for those who spend a lot of time away from their local in-network providers, or for those who suffer from chronic conditions that may require emergency care.¹

How Does an EPO Plan Work?

Because you do not need to get a referral from a primary care doctor to see a specialist (like you do in HMO plans), you can head straight to any in-network provider for care.

For example, say you sprain your ankle days before an important business trip. As an EPO member, you can go straight to any in-network orthopedist who can examine you and send you off with instructions, a prescription for anti-inflammatories, and a brace to wear during your trip.

The tradeoff for this flexibility is that the plan's premiums, copays, and deductible may be more than other plans.

Is an EPO Insurance Plan a Good Option for You?

• You want to go to any in-network provider without getting a referral, and you do not mind paying a little more for that flexibility.
• You do not think you will need to see an out-of-network healthcare professional.

What Is a Preferred Provider Organization (PPO)?

PPOs usually have the highest out-of-pocket costs of these three types of health plans.

The main advantages of a PPO are that you will not need a referral from a primary care doctor to see a specialist, and you can see out-of-network providers, though they will cost you more.

You will have access to any in-network physician, specialist, hospital, clinic, imaging center, etc.

How Does a PPO Plan Work?

If you twist your ankle and it swells up, you can go directly to any in-network or out-of-network orthopedist. You will likely pay more if you see a doctor outside of your network, but that is your choice. This can be especially helpful if you get injured far from home, where there may be no in-network options.

Is a PPO Insurance Plan a Good Option for You?

• You want to have the flexibility to see any in-network provider with no referral and you do not mind paying more out-of-pocket for that flexibility.
• You want to be able to see out-of-network providers, even though you may pay more.
• You do not mind paying higher premiums and copays for the flexibility to see any providers.

Managing Healthcare Costs with CareCredit

If you are looking for an option to help manage your medical bills, consider healthcare financing with the CareCredit credit card. The CareCredit card can help you pay for the care you want and need and make payments easy to manage.* Apply today and use our Acceptance Locator to find a provider near you that accepts CareCredit. Continue your wellness journey by downloading the CareCredit Mobile App to manage your account, find a provider on the go, and easily access the Well U hub for more great articles, podcasts, and videos.

Our Expert Reviewer

Patty Caballero and her team of consultants together have more than 35 years of health insurance knowledge working for some of the biggest health insurance companies in the US. She has knowledge in building brands and strategic initiatives to help consumers better understand their health benefits.