What is the primary difference between HMO and EPO?
Asked by: Jacey Runolfsson | Last update: October 2, 2025Score: 4.5/5 (60 votes)
What is the difference between an EPO and an HMO?
Like HMOs, EPOs cover only in-network care. But the networks are generally larger. They may or may not require referrals from a primary care physician. Premiums are higher than HMOs, but lower than PPOs.
What is the downside of an EPO?
A disadvantage of EPOs is that members that must see an out-of-network provider have to pay all costs for these services with no reimbursement.
What is the biggest difference between HMO EPO PPO and POS healthcare plans?
In a nutshell, these summaries generally say that HMOs and POS plans require a referral from a primary care doctor in order to see a specialist, while PPOs and EPOs do not, and that PPOs and POS plans cover out-of-network care, while HMOs and EPOs do not.
What are the main differences between an HMO and PPO?
HMOs don't offer coverage for care from out-of-network healthcare providers. The only exception is for true medical emergencies. With a PPO, you have the flexibility to visit providers outside of your network. However, visiting an out-of-network provider will include a higher fee and a separate deductible.
What Are The Differences Between HMO, PPO, And EPO Health Plans NEW
Why do doctors prefer PPO over HMO?
HMO plans might involve more bureaucracy and can limit doctors' ability to practice medicine as they see fit due to stricter guidelines on treatment protocols. So just as with patients, providers who prefer a greater degree of flexibility tend to prefer PPO plans.
What is an EPO plan?
A managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan's network (except in an emergency).
What are three disadvantages of HMO?
- If you need specialized care, you will need a referral from your primary care physician to an in-network provider.
- Must see in-network providers for care-less flexibility than a PPO plan.
Why choose PPO over EPO?
EPO: Requires using in-network providers for non-emergency care, leading to lower premiums but no coverage for out-of-network services. Key Differences: PPOs are best for those needing flexibility and frequent specialist visits; EPOs are suitable for those with infrequent healthcare needs and lower costs.
Can EPO be used out of state?
“EPO” is short for “Exclusive Provider Organization.” An EPO plan is one form of health insurance. With an EPO plan, you can use doctors and hospitals within a specific network of providers. However, EPO plans do not allow you to go to a doctor or health care facility outside of that network.
What does EPO not cover?
No Out-of-Network Coverage: EPOs don't cover out-of-network care, except for emergencies. No PCP Requirement: EPOs don't require a primary care physician or referrals. Predictable Costs: Often have lower premiums, deductibles, and copayments. Access to Specialists: Direct access to specialists within the network.
Is EPO worse than HMO?
Regarding EPO versus HMO prices, EPO plans are usually more expensive than HMO policies but less expensive than PPO plans. EPO plans often have a more extensive network than HMO plans and do not give out-of-network benefits like PPO plans. One of the major benefits of EPO vs.
Can an EPO be denied?
If you were denied an emergency protection order, you can file a petition for appeal in the family court within five days of the denial of the order. If you were denied a final protection order, you have the right to appeal your case to the circuit court.
What are the disadvantages of an EPO?
Network restrictions: Even though EPO plans grant access to a relatively large network of providers, the inability to go out-of-network is still a major drawback of these types of plans.
What does 20% coinsurance mean?
For example, if your health insurance plan's allowed amount for an office visit is $100 and your. coinsurance is 20%: • If you've paid your deductible: you pay 20% of $100, or $20. The insurance company pays the rest.
Does an EPO have a number of doctors and hospitals in its network?
An EPO health plan provides a local network of doctors and hospitals that you can visit for your medical needs. Some of the top EPO benefits include: You generally pay lower insurance rates when compared to other types of health plans.
Why would someone choose an HMO instead of a PPO?
HMO plans are generally less expensive than PPO plans, with lower monthly payments, making them ideal if your favorite doctors are already in the network, or if you receive most of your care close to home.
What is the difference between a deductible and an out-of-pocket maximum?
A deductible is the cost a you pay on health care before the health plan starts covering any expenses, whereas an out-of-pocket maximum is the amount a you must spend on eligible healthcare expenses through copays, coinsurance, or deductibles before the health plan starts covering all covered expenses.
What does 100% coinsurance mean?
100% coinsurance: You're responsible for the entire bill. 0% coinsurance: You aren't responsible for any part of the bill — your insurance company will pay the entire claim.
Why do doctors not accept HMO?
HMO plans frequently need primary care physicians to refer patients and have constrained provider networks, which may frustrate some physicians. Yet, HMO plans often have lower consumer out-of-pocket payments, which may appeal to physicians who wish to provide appropriate care.
Why do people not like HMO plans?
Cons of HMO Plans
Referrals Needed for Specialists: To see a specialist, you must first get a referral from your primary care doctor, which can delay care. Less Flexibility: If you often need care outside your network or prefer more choice in doctors, an HMO may feel restrictive compared to a PPO plan.
What is the primary problem with an HMO?
Without a referral, you don't have permission for those services, and the HMO won't pay for them. The benefit of this system is fewer unnecessary services. The drawback is that you have to see multiple providers (a primary care provider before a specialist) and pay copays or other cost-sharing for each visit.
Why is EPO better than a PPO?
EPO and PPO plans are both solid options that can help cover medical costs for you and your family. If you're looking for coverage that reaches beyond a limited network, then a PPO may be right for you. However, EPOs tend to be more affordable and offer sufficient coverage for in-network medical services.
Who takes EPO insurance?
EPO plans contract with doctors and hospitals to provide care to the health plan's members. These providers are called “network providers” or “in-network providers,” and they include physicians, specialists, and facilities, like labs, hospitals, and urgent care centers.
Do HMOs still exist?
An HMO is a health maintenance organization. The Department of Managed Health Care (DMHC) oversees all HMOs in California and some other kinds of health plans.