PPO vs HMO vs EPO: How the Plan Types Differ

These four labels describe how a health plan uses its network. A provider that has a contract with your plan is called in-network. A provider without a contract is out-of-network.

Two more terms come up often. A primary care provider is a doctor, nurse practitioner, clinical nurse specialist, or physician assistant who provides, coordinates, or helps you access a range of health care services. A referral is a written order from your primary care provider for you to see a specialist or get certain health care services.

The table below compares how the plan types usually work. It covers process only, not prices. Rules vary by plan, and an individual plan can add its own conditions, so treat each cell as a starting point and confirm it in your plan documents.

No type is right for everyone. The useful question is which set of rules fits the way you use care, such as which doctors you see and whether you travel.

In many HMOs, you need a referral before you can get care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for the services. A PPO, by contrast, lets you use providers outside the network without a referral.

If a plan covers out-of-network services, you usually pay more to see an out-of-network provider. If it does not, you may, in most non-emergency cases, be responsible for paying the full amount that provider charges.

Even when a plan covers some out-of-network care, the provider may ask you to pay the difference between its billed charge and the amount your plan covers. That is called a balance bill. Example: say a provider charges $500 and your plan's allowed amount is $300. The provider may bill you for the remaining $200, on top of your usual share of the $300.

If you have most job-based or individual health insurance, federal law protects you in some situations. In most cases, the No Surprises Act protects you from unexpected out-of-network bills for emergency room visits, for certain non-emergency care at in-network hospitals, hospital outpatient departments, and ambulatory surgical centers, and for air ambulance services. Our article on balance billing covers this in more detail.

Check before you choose a plan, not after your first visit. Health plans usually have online provider directories, but directories aren't always accurate. Networks can also change, so one check is not enough.

Plan type is only one part of the decision, and the label does not tell you every rule. These questions help you compare plans on the rules that affect your day-to-day care.