HMO vs PPO vs EPO vs POS - Health Plan Differences

There are four major “types” of insurance plans: HMO, PPO, EPO, and POS. HMO and PPO are the most popular. EPO and POS are “hybrid” HMO/PPO plans.

HMO

HMO stands for Health Maintenance Organization. Out of the four types of plans, HMO plans are generally the least costly. However, the lower cost is associated with some tradeoffs. HMO plans usually require members to select a Primary Care Physician (PCP). Members must receive a referral from their PCP in order to see a specialist doctor, except in the case of healthcare emergencies. This means that if a member had a skin problem, he or she would have to visit the PCP to get a referral to a dermatologist. Additionally, an HMO plan requires members to visit a healthcare provider within the plan’s network. An HMO plan usually does not cover any costs associated with visits to healthcare providers outside of the plan’s network.

PPO

PPO stands for Preferred Provider Organization. Compared to HMO plans, PPO plans usually cost more. However, members do not have to see their PCP to see a specialist. Like an HMO plan, a PPO plan also has a set healthcare provider network. However, members are allowed to visit a provider outside of the PPO plan network and still receive coverage, though the coverage is reduced if they go outside of the network. For example, if a member visits a provider in the network, the insurance company may cover 70% of the cost, whereas only 50% of the cost is covered if the member visits a provider outside of the network.

EPO

EPO stands for Exclusive Provider Organization. An EPO plan is a hybrid between an HMO plan and a PPO plan. EPO plans are similar to HMO plans in that members are required to visit a provider within the plan’s network. EPO plans are similar to PPO plans in that members do not have to see their PCP to see a specialist.

POS

POS stands for Point of Service. A POS plan is another hybrid between an HMO plan and a PPO plan. POS plans are similar to HMO plans in that members are required to receive a referral from their PCP in order to see a specialist. POS plans are similar to PPO plans in that members are allowed to visit providers outside of the plan’s network and still receive coverage, though the coverage is reduced if they go outside of the network.