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What is the Difference Between HMO, EPO and PPO: Medicare, Marketplace, and More

One of the most common decisions within health insurance is whether to go with an HMO or PPO and (if you’re on the marketplace) if you want a EPO. Let’s break it down.

PPO

PPOs will give you the most flexibility. You will not need a PCP which is primary care physician. You will also not need a referral to see a specialist. So, what does that mean? Basically, if you want to see anyone other than a general practitioner, with other types of plans you need to first go to your PCP to have them refer you to a specialist like a cardiologist or neurologist. This can be difficult for many reasons.

  1. It’s an extra visit
  2. You have less control
  3. Waiting

Now these types of plans usually have higher monthly premiums when compared with HMOs or EPOs. However you will have coverage in and out of network. This applies to marketplace plans, private insurance, short term medical plans, Medicare Advantage (more on that in just a moment) and even dental insurance.

Dental

A PPO for dental insurance is also highly preferred. When discussing general health insurance, it is often not too difficult to find a PCP who is in network. This is often not the case with dentists. It can be very difficult to find a dentist who accepts your DHMO. Also, because of the way DHMO dentists bill, many patients report dissatisfaction and feeling rushed. 

Marketplace

If you definitely want a PPO and you are under 65, they can be very difficult to find the on marketplace. Of course, there are a few exceptions, but they are few and far between. If you are intent on a marketplace plan and need more flexibility, then EPOs are your best option.

STM

If you really need a PPO then private insurance will be easier to find. However, private insurance can be rather pricey. So, you may want to look into a short term medical plan.

Short term medical plans can be a great way for a younger mostly healthy person to have a large range of benefits at a lower price. Benefits include:

  1. Lower premium
  2. Year round enrollment
  3. Nationwide PPO coverage
  4. Customizable

However, short term medical plans are not ideal for all people and they are not even available in all states. They will not cover pregnancy and although some preexisitng conditions will be covered after the first year of a multi-year plan, if you have a more complex condition, it may not be covered at all. These types of plans are also not ideal for people with young children.

Medicare Advantage

PPOs may be available for Medicare Advantage plans as well. Medicare Advantage is a replacement for Original Medicare. A Medicare Advantage plan (even a PPO) will STILL not offer you the same freedom as Original Medicare with a Supplement, but they can be an alternative if you are looking for a broader range of benefits with a lower monthly premium. Most of our clients still opt for a Medigap plan (with good reason) and they are far more popular than Medicare Advantage Plans.

EPO

EPOs split the difference between a PPO and HMO. They are much more common on the marketplace. Although HMOs are still more common, you will likely find that there are almost as many EPOs to choose from.

Usually, with EPOs you will not need a PCP or referral for a specialist. However, you will have to stay in network for non-emergency medical care.

Like all other plans on the marketplace, you can find EPOs in either the Bronze, Silver, Gold or Platinum tier.

HMO

Finally, there are HMOs. HMOs are usually your least expensive option. However, you must operate within network. If you choose to go out of network, you will NOT be covered.

The exception to this is in a true medical emergency. If you need immediate and urgent medical care at a hospital, under the ACA you cannot be charged more for the ER at an out of network facility vs. in network. Balance billing is a thing of the past. 

With HMOs you will also need a PCP. You will also need a referral to see a specialist. Often if you have insurance through your employer, you will have an HMO and PPO option. HMOs are also plentiful on the marketplace and of course, if you choose Medicare Advantage there are many HMOs to choose from.

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Jesse Smedley is the Principal Broker for iHealthBrokers and the founder, president, and CEO of Smedley Insurance Group, Inc. and iHealthBrokers.com. Since the inception of SIG in 2007, Jesse has been dedicated to helping people save money on their health insurance by providing them with resources to educate themselves on all their health insurance options, both under age 65 and Medicare beneficiaries. He is featured in many publications as well as writes regularly for expert columns regarding health insurance and Medicare.

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