HMO / PPO / EPO / POS | Glossary | hioscar

If you have an HMO (Health Maintenance Organization) plan, your insurance coverage is usually limited to care from a network of providers that work for or contract with your insurance company. Put simply: If you get care in the network, you’re covered. If you go to someone outside the network, you’re not. Also, if you want to see a specialist, you may need a referral from your primary care doctor, which is sometimes called a “gatekeeper”.

If you have a PPO (Preferred Provider Organization) plan, you generally pay less if you use providers that are in the network because they have negotiated lower rates with your insurance company. But you also have the option to see doctors outside of the network. You’ll typically pay more for PPO plans, since they require higher cost-sharing (like copays) when you see doctors outside their network of preferred doctors. Referrals are not required to see a specialist.

With an EPO (Exclusive Provider Organization) plan, your care is covered when you see a doctor in the network. If you get care with doctors outside the network, it won’t be covered except in certain situations (like emergencies, or if there are no in-network options available). Referrals aren’t required to see a specialist.

With a POS (Point of Service) plan, your coverage works like a hybrid of an HMO and PPO plan. It provides lower costs for care when you use in-network doctors, and includes coverage for out-of-network care with a referral. POS plans require that you elect a primary care doctor and obtain a referral to get care with a specialist, even if they’re in-network.